Formulations and methods of using nitric oxide mimetics in cancer treatment

ABSTRACT

The present invention relates to methods and formulations for inhibiting, treating and preventing a malignant cell phenotype, cell, tumor and/or disease. Administration of nitric oxide mimetics, such as low doses, is sufficient to increase, restore or maintain nitric oxide-mediated signaling in cells so that malignant cell phenotypes, cells, tumors and/or diseases are inhibited or prevented. These methods and formulations are particularly useful in treating and preventing cancer in animals.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application claims the benefit of U.S. Provisional Application Ser. Nos. 60/362,969 filed Mar. 6, 2002, and 60/362,620 filed Mar. 7, 2002, and U.S. patent application Ser. No. 10/042,039, filed Oct. 25, 2001 now abandoned, which are herein incorporated by reference. This application is a continuation of U.S. patent application Ser. No. 10/384,499, filed Mar. 6, 2003, now U.S. Pat. No. 7,678,391, issued Mar. 16, 2010, which is a continuation-in-part of U.S. patent application Ser. No. 10/042,039 filed on Oct. 25, 2001, now abandoned, which is a continuation-in-part of U.S. application Ser. No. 09/842,547, filed Apr. 26, 2001, now U.S. Pat. No. 6,946,484, issued Sep. 20, 2005, which claims the benefit of U.S. Provisional Application Nos. 60/277,469, filed Mar. 21, 2001, and 60/199,757, filed Apr. 26, 2000, which are herein incorporated by reference in their entirety.

FIELD OF THE INVENTION

The present invention relates to methods and formulations for inhibiting, treating and preventing a malignant cell phenotype, cell, tumor and/or disease. We have now found that the mechanism by which hypoxia and hyponitroxia have impact upon cellular phenotype is not necessarily mediated solely by the lack of oxygen but rather also from a deficiency in nitric oxide mediated signaling. Accordingly, as demonstrated herein, administration of nitric oxide mimetics, such as low doses, is sufficient to increase, restore or maintain nitric oxide-mediated signaling in cells so that malignant cell phenotypes, cells, tumors and/or diseases are inhibited or prevented. Thus, provided herein are formulations and methods of using these formulations to deliver low doses of nitric oxide mimetics to cells at levels which inhibit a malignant cell phenotype, cell, tumor and/or disease to treat and/or prevent development of a malignant cell phenotype, cell, tumor and/or disease but which reduce or avoid development of unwanted effects of the NO mimetics. These methods and formulations are particularly useful in treating and preventing cancer in animals.

BACKGROUND OF THE INVENTION

Hypoxia or oxygen tension below normal physiologic levels in cells results in physiologic as well as pathologic alterations in the cells, which alterations have been associated with differential gene expression. For example, hypoxia affects endothelial cellular physiology in vivo and in vitro in various ways including modulating the transcriptionally-regulated expression of vasoactive substances and matrix proteins involved in modulating vascular tone or remodeling the vasculature and surrounding tissue (Faller, D. V. Clin. Exp. Pharmacol. and Physiol. 1999 26:74-84). Hypoxia in solid tumors has been shown to protect cancer cells from being killed by X-irradiation and leads to resistance to certain cancer drugs. Hypoxia also appears to accelerate malignant progression and increase metastasis (Brown, J. M. Cancer Res. 1999 59:5863-5870).

Low oxygen levels have been shown to enhance invasiveness in a number of cell types, and likely promote invasive phenotypes in biological environments such as the core of rapidly growing tumors. Studies in our laboratory suggest that this effect is mediated via a reduction in nitric oxide (NO) production. For example, the inhibition of endogenous NO production (that occurs under hypoxic conditions or in the presence of a NOS inhibitor) was shown to up-regulate both the expression of the urokinase receptor (uPAR, a pro-invasive molecule) and metastasis. Further, the hypoxic upregulation of (uPAR) and metastasis was completely abrogated by the addition of very low concentrations of NO-mimetics.

Nitric oxide has been implicated in various biological processes. For example, nitric oxide is a biological messenger molecule responsible for endothelium derived vascular relaxation and neurotransmission. Nitric oxide, at what these researchers refer to as high levels, is also known as a mediator for anti-tumor and anti-bacterial actions of macrophages. Nitric oxide has also been demonstrated to play a modulatory role on cytokine-induced expression of matrix metalloproteinase-9 and tissue inhibitors of metalloproteinases (Eberhardt et al. Kidney International 2000 57:59-69).

Soluble guanylyl cyclase (sGC) is the best defined downstream target of NO. However, since NO is a pleiotropic molecule, it is likely that there are other molecular targets that mediate NO action. For example, it is very likely that NO could attenuate gene expression via currently unknown mechanisms and, as such, impact various cellular functions, such as growth, proliferation, migration, apoptosis, and the like. The heterodimeric protein, i.e., sGC, catalyzes the conversion of guanosine 5′-triphosphate (GTP) to cyclic guanosine monophosphate (cGMP). Nitric oxide binds to the heme moiety of sGC, inducing a number of conformational changes that result in its activation, cGMP is a potent second messenger that allows NO to transmit its signal to downstream effectors. Elevated levels of cGMP have been negatively correlated with vascular smooth muscle growth and have been shown to prevent platelet aggregation as well as the adherence of neutrophils to endothelial cells. Further, cGMP levels play a role in gene regulation. A cGMP analogue (8-Br-cGMP) has been shown to prevent the hypoxic induction of VEGF. The endogenous inhibition of endothelin-1 (ET-1) by NO is also mediated through a guanylate cyclase/cGMP-dependent mechanism.

There are several cGMP target proteins that could mediate NO-regulated gene expression. These include cGMP-dependent protein kinase (PKG), cGMP-activated phosphodiesterases (PDEs), and cGMP-gated ion channels, and under certain conditions, cAMP-dependent protein kinases. Of these, it is thought that PKG is responsible for the majority of cGMP's intracellular actions. PKG is a serine/threonine protein kinase that is selectively activated by cGMP binding. Upon activation, PKG phosphorylates many intracellular targets, often resulting in alterations in gene expression. For example, PKG has been shown to modulate the transcription of various genes through its activation of factors such as AP-1 and the serum response element. Similarly, Idriss et al. has shown that the c-fos promoter is activated by a PKG dependent mechanism.

Clinical and experimental data suggest that nitric oxide plays a role in promoting solid tumor growth and progression. For example, nitric oxide generation by inducible nitric oxide synthase (iNOS) has been implicated in the development of prostate cancer (Klotz et al. Cancer; National Library of Medicine, MDX Health Digest 1998 82(10):1897-903), as well as in colonic adenocarcinomas and mammary adenocarcinomas (Lala, P. K. and Orucevic, A., Cancer and Metastasis Reviews 1998 17:91-106). In addition, nitric oxide has been suggested to play an important role in the metabolism and behavior of lung cancers, and in particular adenocarcinomas (Fujimoto et al. Jpn. J. Cancer Res 1997 88:1190-1198). In fact, it has been suggested that tumor cells producing or exposed to what these researchers refer to as low levels of nitric oxide, or tumor cells capable of resisting nitric oxide-mediated injury undergo a clonal selection because of their survival advantage (Lala, P. K. and Orucevic, A. Cancer and Metastasis Review 1998 17:91-106). These authors suggest that these tumor cells utilize certain nitric oxide-mediated mechanisms for promotion of growth, invasion and metastasis and propose that nitric oxide-blocking drugs may be useful in treating certain human cancers. There is also evidence indicating that tumor-derived nitric oxide promotes tumor angiogenesis as well as invasiveness of certain tumors in animals, including humans (Lala, P. K. Cancer and Metastasis Reviews 1998 17:1-6).

However, nitric oxide has been reported to reverse production of vasoconstrictors induced by hypoxia (Faller, D. G. Clinical and Experimental Pharmacology and Physiology 1999 26:74-84). In addition, the nitric oxide donors sodium nitroprusside, S-nitroso-L-glutathione and 3-morpholinosydnonimine in the micromolar range (IC₅₀=7.8, 211 and 490 μM, respectively) have been demonstrated to suppress the adaptive cellular response controlled by the transcription factor hypoxia-inducible factor-1 in hypoxically cultured Hep3B cells, a human hepatoma cell line (Sogawa et al. Proc. Natl. Acad. Sci. USA 1998 95:7368-7373). The nitric oxide donor sodium nitroprusside (SNP; 150 μM) has also been demonstrated to decrease hypoxia-induced expression of vascular endothelial growth factor, an endothelial cell mitogen required for normal vascular development and pathological angiogenic diseases such as cancer and iris and retinal neovascularization (Ghiso et al. Investigative Opthalmology & Visual Science 1999 40(6):1033-1039). In these experiments, 150 μM SNP was demonstrated to completely suppress hypoxia-induced VEGF mRNA levels for at least 24 hours in immortalized human retinal epithelial cells.

High levels of nitric oxide, when induced in certain cells, can cause cytostasis and apoptosis. For example, Xie et al. have demonstrated exposure to high levels of nitric oxide (producing approximately 75 μM nitrite; see FIG. 5A of Xie et al.) to be an exploitable phenomenon to promote death (see FIGS. 6A and 6B of Xie et al.) in murine K-1735 melanoma cells (J. Exp. Med. 1995 181:1333-1343). In addition, WO 93/20806 discloses a method of inducing cell cytostasis or cytotoxicity by exposing cells to a compound such as spermine-bis(nitric oxide) adduct monohydrate at 500 μM which is capable of releasing nitric oxide in an aqueous solution. The compounds are taught to be useful in the treatment of tumor cells as well as in antiparasitic, antifungal and antibacterial treatments. Use of a mega-dosing regimen is suggested, wherein a large dose of the nitric oxide releasing compound is administered, time is allowed for the active compound to act, and then a suitable reagent such as a nitric oxide scavenger is administered to the individual to render the active compound inactive and to stop non-specific damage. It is taught at page 14, line 25-30 of WO 93/20806 that 3-(n-propyl amino)propylamine bis(nitric oxide) adduct, diethylamine-bis(nitric oxide) adduct sodium salt, isopropylamine-bis(nitric oxide) adduct sodium salt, sodium trioxodinitrate (II) monohydrate, and N-nitrosohydroxylamine-N-sulfonate did not significantly affect cell viability at concentrations up to 500 μM.

U.S. Pat. No. 5,840,759, U.S. Pat. No. 5,837,736, and U.S. Pat. No. 5,814,667, disclose methods for using mg/kg quantities of nitric oxide releasing compounds to sensitize hypoxic cells in a tumor to radiation. These patents also disclose methods of using the same nitric oxide-releasing compounds at mg/kg levels to protect non-cancerous cells or tissue from radiation, to sensitize cancerous cells to chemotherapeutic agents, and to protect non-cancerous cells or tissue from chemotherapeutic agents. Compounds used in these methods spontaneously release nitric oxide under physiologic conditions without requiring oxygen. These patents teach administration of the nitric oxide-releasing compound from about 15 to about 60 minutes prior to therapy. Typical doses of the nitric oxide releasing compound administered are suggested to be from about 0.1 to about 100 mg of one or more nitric oxide releasing compounds per kg of body weight. Concentrations of the nitric oxide releasing compounds DEA/NO and PAPA/NO demonstrated to increase the sensitivity of MCF7 breast cancer cells and V79 fibroblasts to melphalan, thiotepa, mitomycin C, SR4233 and cisplatin in vitro were in the millimolar range while 70 mg/kg of DEA/NO was demonstrated to increase the survival of mice administered the chemotherapeutic agent melphalan in the in vivo KHT tumor model.

U.S. Pat. No. 5,700,830 and WO 96/15781 disclose methods for inhibiting adherence between cancerous cells and non-cancerous cells in an animal by administering to the animal a nitric oxide-releasing compound containing a nitric oxide-releasing N₂O₂ functional group. However, studies indicate that cancer cell adhesion to and spreading along the vessel wall leading to extravasation is not an obligatory event in metastasis (Morris et al. Exp. Cell. Res. 1995 219:571-578).

WO 98/58633 discloses a microdose nitric oxide therapy for alleviating vascular conditions associated with a reduction in nitric oxide production or an attenuation of nitric oxide effect.

SUMMARY OF THE INVENTION

The present invention provides methods and formulations for administering nitric oxide mimetics to cells to inhibit, to treat and to prevent a malignant cell phenotype, cell, tumor and/or disease. In certain preferred aspects, the nitric oxide mimetic is administered in a low dose. Advantageously, in certain aspects, the nitric oxide mimetics of the present invention increase the efficacy of palliative treatment, by relieving or reducing the intensity of uncomfortable symptoms associated with cancer, such as pain, nausea, and shortness of breath.

In one aspect, the present invention provides a method useful for controlling, treating, and/or preventing cancer, malignancies, neoplasm, hyperplasia, hypertrophy, dysplasia and/or tumor angiogenesis, comprising administering a nitric oxide mimetic to an animal to control, treat and/or prevent cancer, malignancies, neoplasm, hyperplasia, hypertrophy, metastasis, dysplasia and/or tumor angiogenesis.

In one embodiment, the nitric oxide mimetic is administered at a low dose. In another embodiment, the nitric oxide mimetic is administered at a level which delays and/or reduces development of tolerance to the nitric oxide mimetic and/or unwanted side effects, including headache, flushing, syncope, dizziness and hypotension. In another embodiment, the nitric oxide mimetic is administered alone or in combination with an antimalignant therapeutic agent. In yet another embodiment, the nitric oxide mimetic is administered in combination with agents intended for palliative purposes including pain relief, improving physical strength and quality of life.

In another embodiment, the nitric oxide mimetic (1) inhibits the metastatic potential of a malignant cell phenotype, cell, tumor and/or disease preferably by decreasing the invasiveness, progression, growth and/or metastases of cells, tumors and/or diseases exhibiting a malignant phenotype; inhibiting the survival and/or growth of cells, tumors and/or diseases exhibiting a malignant phenotype; decreasing the progression and/or metastases of cells, tumor volume and/or diseases exhibiting a malignant phenotype; increasing the regression of cells, tumors and/or diseases exhibiting a malignant phenotype; and/or facilitating the killing of cells, tumors and/or diseases exhibiting a malignant phenotype; (2) maintains a malignant cell, tumor and/or disease in a dormant state at its primary and/or secondary site; (3) enhances the efficacy of, increases sensitivity to, and/or prevents or decreases the resistance of a malignant cell, tumor and/or disease to an antimalignant therapeutic modality; or (4) inhibits or prevents cell, tumor and/or disease angiogenesis in animals at high risk of developing cancer and/or exposed to factors known to decrease nitric oxide activity in an animal, optionally wherein said factors include decreased arginine levels, exposure to nitric oxide synthase antagonists, exposure to nitric oxide scavengers, changes in nitric oxide synthase expression, change in cofactors, glucose deprivation, surgical procedures, administration of anaesthetic agents, administration of pharmacologic agents which alter circulation, traumatic injuries, physical trauma, blood loss, decreased blood volume, or hemorrhage, or combinations thereof.

In another embodiment, the cells exhibiting the malignancies are selected from malignant cells, invasive cells, cells and tissue(s) that facilitate the malignant process, and combinations thereof; optionally wherein the malignant cell phenotype is controlled, treated or prevented by improving response to an antimalignant therapeutic modality.

In another embodiment, the nitric oxide mimetic (1) inhibits or retards the metastasis of existing tumors in a patient preferably by decreasing the invasiveness, progression, growth and/or metastases of existing tumor(s); inhibiting the survival and/or growth of existing tumor(s); decreasing the progression and/or metastases of existing tumor(s); increasing the regression of existing tumor(s); and/or facilitating the killing of existing tumor(s); (2) maintains a malignant tumor in a dormant state at its primary and/or secondary site; (3) enhances the efficacy of, increases sensitivity to, and/or prevents or decreases the resistance of tumor(s) to an antimalignant therapeutic modality; or (4) inhibits or prevents tumor angiogenesis in animals at high risk of developing cancer and/or exposed to factors known to decrease nitric oxide activity in an animal, optionally wherein said factors include decreased arginine levels, exposure to nitric oxide synthase antagonists, exposure to nitric oxide scavengers, changes in nitric oxide synthase expression, change in cofactors, glucose deprivation, surgical procedures, administration of anaesthetic agents, administration of pharmacologic agents which alter circulation, traumatic injuries, physical trauma, blood loss, decreased blood volume, or hemorrhage, or combinations thereof.

In another embodiment, the nitric oxide mimetic (1) inhibits or retards the metastasis of a cancerous disease in a patient preferably by decreasing the invasiveness, progression, growth and/or metastasis of the disease; inhibiting the survival and/or growth of the disease; decreasing the progression and/or metastasis of the disease; increasing the regression of the disease; and/or facilitating the curing and/or treatment of the disease; (2) produces or maintains remission of the disease; (3) enhances the efficacy of, increases sensitivity to, and/or prevents or decreases the resistance to an antimalignant therapeutic modality used to treat the disease; or (4) inhibits or prevents development of the disease in animals at high risk of developing cancer and/or exposed to factors known to decrease nitric oxide activity in an animal, optionally wherein the factors include decreased arginine levels, exposure to nitric oxide synthase antagonists, exposure to nitric oxide scavengers, changes in nitric oxide synthase expression, change in cofactors, glucose deprivation, surgical procedures, administration of anaesthetic agents, administration of pharmacologic agents which alter circulation, traumatic injuries, physical trauma, blood loss, decreased blood volume, or hemorrhage, or combinations thereof.

In another embodiment, the cells exhibiting the malignancies are selected from malignant cells, invasive cells, cells and tissue(s) that facilitate the malignant process, and combinations thereof; optionally wherein the malignant cell phenotype is controlled, treated or prevented by improving response to an antimalignant therapeutic modality.

In another embodiment, cancer is diagnosed or monitored by measuring a tumor selective marker present in the animal.

In another embodiment, the nitric oxide mimetic decreases, maintains, or decelerates increases of the level of the tumor marker.

In another embodiment, the cancer comprises gastric cancer, gastrointestinal cancer, testicular cancer, prostate cancer, prostatic adenocarcinoma, breast cancer, metastatic melanoma, lung cancer, the cancers set forth in Table 2 or combinations thereof. Optionally, the cancer or other malignancies, neoplasm, hyperplasia, hypertrophy, dysplasia and/or tumor angiogenesis in an animal comprises benign prostatic hyperplasia or molar pregnancy.

In another embodiment, the nitric oxide mimetic comprises nitric oxide, a nitric oxide donor, a nitric oxide prodrug, a compound that generates or releases nitric oxide through biotransformation, a compound that generates nitric oxide spontaneously or spontaneously releases nitric oxide, or a compound which generates nitric oxide, or combinations thereof.

In another embodiment, the nitric oxide mimetic is (1) a nitric oxide donor selected from nitroglycerin (GTN), isosorbide 5-mononitrate (ISMN), isosorbide dinitrate (ISDN), pentaerythritol tetranitrate (PETN), erthrityl erythrityl tetranitrate (ETN), N-hydroxyl-L-arginine (NOHA), N⁶-(1-iminoethyl)lysine (L-NIL), L-N⁵-(1-iminoethyl) ornithine (LN-NIO), N^(ω)-methyl-L-arginine (L-NMMA), S-nitrosoglutathione (SNOG), S,S-dinitrosodithiol (SSDD), N-[2-(nitroxyethyl)]-3-pyridinecarboxamide (nicorandil), sodium nitroprus side (SNP), S-nitroso-N-acetylpenicilamine (SNAP), 3-morpholino-sydnonimine (SIN-1), molsidomine, DEA-NONOate (2-(N,N-diethylamino)-diazenolate-2-oxide), and spermine NONOate (N-[4-[1-(3-aminopropyl)-2-hydroxy-2-nitrosohydrazino]butyl]-1,3-propanediamine); (2) a compound that activates stages of NO pathway, a compound which enables or facilitates NO utilization by a cell, a compound which directly activates guanylyl cyclase, or a phosphodiesterase inhibitor, or combinations thereof; (3) a non-specific phosphodiesterase inhibitor, a dual-selective phosphodiesterase inhibitor, a type I, II, III, IV, V, VI, VII, VIII, IX, X, or XI phosphodiesterase inhibitor, or combinations thereof; or (4) a protein kinase G activator.

In another embodiment, the antimalignant therapeutic agent includes radiation therapy (radiotherapy), thermal therapy, immunotherapy, hormonal therapy, or single agent chemotherapy, combination chemotherapy, chemo-irradiation, adjuvant therapy, neoadjuvant therapy, palliative therapy or combinations thereof. Optionally, the antimalignant therapeutic modality comprises radiation therapy, and the nitric oxide mimetic is a nitric oxide, a nitric oxide donor, a compound that generates or releases nitric oxide through biotransformation, or a compound that generates nitric oxide spontaneously or spontaneously releases nitric oxide only in the presence of oxygen, or combinations thereof, wherein the nitric oxide mimetic is administered during the radiation therapy.

In another embodiment, the chemotherapy comprises administration of chemotherapeutic agent that is an anti-angiogenic agent, an antimetabolite, an antibiotic, an endothelin activating agent, an enzyme inhibitor, a hormonal agent, ocreotide acetate, a microtubule-disruptor agent, a microtubule-stabilizing agent, a vinca alkaloid, an epipodophyllotoxin, a topoisomerase inhibitor; a prenyl-protein transferase inhibitor, hydroxyurea, procarbazine, mitotane, hexamethylmelamine, a platinum coordination complex, a biological response modifier, a growth factor, an immune modulator, or a monoclonal antibody, or a combination thereof.

In another embodiment, the palliative therapy comprises glucocorticoid steroids, narcotic pain relief agents, anti-depressants, sex hormones, or a combination thereof.

In another embodiment, the dose of nitric oxide mimetic is at least 3- to 10,000-fold lower, preferably 100-10,000 fold lower than a dose of nitric oxide mimetic that produces vasodilation.

In another embodiment, the nitric oxide mimetic is an organic nitrate and the mimetic is administered at a dose of at least 3- to 10,000-fold lower, preferably 100-10,000 fold lower than the dose of nitric oxide mimetic known to produce vasodilation.

In another embodiment, the nitric oxide mimetic is a known vasodilatory compound and the mimetic is administered at a dose of at least 3- to 10,000-fold lower, preferably 100-10,000 fold lower than the dose of nitric oxide mimetic known to produce vasodilation

In another embodiment, the nitric oxide mimetic is selected from the group consisting of a calcium channel blocker, an α-adrenergic receptor antagonist, a β-adrenergic receptor agonist, a phosphodiesterase inhibitor, a cAMP-dependent protein kinase activator, a superoxide scavenger, a potassium channel activator, a benzodiazepine, an adrenergic nerve inhibitor, an antidiarrheal agent, a HMG-CoA reductase inhibitor, an adenosine receptor modulator, a adenylyl cyclase activator, an endothelin receptor antagonist, a bisphosphonate, a cGMP-dependent protein kinase activator, a guanylyl cyclase activator and a SOC inhibitor.

These methods and formulations are particularly useful in controlling cancer by reducing its growth and improving response to therapy. For example, methods and formulations of the present invention can inhibit metastasis, invasiveness and progression of cells, tumors and/or diseases exhibiting a malignant phenotype. In addition, the methods and formulations can induce or maintain dormancy or remission of cells, tumors and/or diseases exhibiting a malignant phenotype at primary as well as secondary sites. Further, these methods and formulations can prevent or decrease development of resistance of cells, tumors and/or disease exhibiting a malignant phenotype to antimalignant therapeutic modalities, as well as increase the efficacy of antimalignant therapeutic modalities.

The methods and formulations of the present invention are also very useful in preventing a malignant cell phenotype, cell, tumor and/or disease that can develop upon exposure of cells to conditions and/or therapeutic agents which lead to a deficiency in nitric oxide mimetic activity in the cells.

The methods and formulations of the present invention are also useful in inhibiting development of a more aggressive malignant cell phenotype in cancer cells, tumors, and/or diseases, which can occur upon exposure to factors which induce such development.

In addition, these methods and formulations are useful in diagnosing and monitoring a malignant cell phenotype, cell, tumor and/or disease in an animal via detection of levels of one or more markers indicative of a malignant phenotype following administration of a low dose of a nitric oxide mimetic. No change, a decrease or deceleration in the increase of the level of one or more of these markers in an animal following administration of a low dose nitric oxide mimetic as compared to the level of the marker in the animal prior to administration of the low dose nitric oxide mimetic is indicative of a malignant phenotype in the animal. Accordingly, the methods and formulations of the present invention provide new therapeutic and diagnostic approaches for the treatment and prevention of cancer in animals.

Advantageously, the compounds, and methods described herein prolong cancer remission, prevent the recurrence of cancer, decrease cancer markers, reduce tumor volume, reduce pain, discomfort, and disability (morbidity), increase the quality of life associated with antimalignant therapeutic modalities, decrease cachexia, and reduce the need for anti-emetic agents and narcotic pain killers.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a histogram showing the effect of GTN and SNP on the in vitro invasion by MDA-MB-231 invasive breast cancer cells in hypoxic (1% O₂) conditions as compared to normal (20% O₂) conditions. Cells were coated onto Matrigel-coated membranes and incubated under hypoxic or normal conditions, alone or in the presence of nitric oxide mimetics. The invasion index (% of control), which is taken to be a measure of the invasive potential of the cells for each treatment, was determined by staining the cells that invaded through the membrane and counting them. The first bar depicts the invasion index of cells cultured under normal conditions (20% O₂). The second bar depicts the invasion index of cells cultured under hypoxic conditions (1% O₂). The third bar depicts the invasion index of cells cultured under hypoxic conditions (1% O₂) and administered 10⁻¹⁰ M SNP. The fourth bar depicts the invasion index of cells cultured under hypoxic conditions (1% O₂) and administered 10⁻¹¹ M GTN. The values indicated by “*” were significantly different (p<0.05, n=6) using the Student-Newman-Keuls post-hoc test for pair-wise multiple comparison procedures.

FIG. 2 is a histogram showing the lung colonization ability of Bl6F10 mouse melanoma cells incubated for 12 hours in 1% or 20% O₂ in the presence or absence of 2×10⁻¹¹ M (20 pM) GTN and injected i.v. (tail vein) into C57Bl6 female mice. Fourteen days later, mice were sacrificed and lungs were removed and fixed in Bouin's fixative. Both melanotic and amelanotic metastatic colonies were counted under a dissecting microscope. The first bar depicts the number of nodules observed in lungs of mice injected with cells cultured in normal conditions (20% O₂). The second bar depicts the number of nodules observed in lungs of mice injected with cells cultured in normal conditions (20% O₂) and administered 2×10⁻¹¹ M GTN. The third bar depicts the number of nodules observed in lungs of mice injected with cells cultured in hypoxic conditions (1% O₂). The fourth bar depicts the number of nodules observed in lungs of mice injected with cells cultured in hypoxic conditions (1% O₂) and administered 2×10¹¹ M GTN.

FIG. 3 shows circulating prostate specific antigen (PSA) levels in two patients, Patient A (FIG. 3A) and Patient B (FIG. 3B) who had undergone radical prostectomy. A sharp decline in plasma PSA levels was observed in both patients within two months of administration of low dose NO mimetic therapy. In Patient A, this decline continued throughout the course of the study. In Patient B, further increases in PSA levels were minimal. Plasma PSA levels were measured using a radioimmunoassay that has an accuracy of ±0.1 ng/ml.

FIG. 4 illustrates the effect of hypoxia (0.5% O₂) on cellular cGMP Levels in MDA-MB-231 breast carcinoma cells. Cells were cultured for 6 hrs in 20 or 0.5% O₂ and in the presence or absence of GTN (1 mM). IBMX (500 mM) was included in the culture medium in order to inhibit PDE activity, thereby allowing for a measurable accumulation of cGMP. Culture in hypoxic conditions resulted in a 44% reduction in cGMP levels. This effect was completely prevented by GTN (1 mM). Values are presented as fM cGMP per mg of cellular protein+/−standard deviation. Value indicated by an asterisk (*) is significantly different as determined by a one-way analysis of variance followed by the Tukey test for pairwise multiple comparisons (N=3, P<0.05).

FIG. 5 illustrates the effect of GTN and SNP on the hypoxic upregulation of in vitro invasion by MDA-MB-231 cells. NO-mimetic drugs were added to the cells at the beginning of the 24-h assay and the invasion index for each treatment was calculated after counting the cells that penetrated through the membrane. Bars represent the mean, normalized, invasion indices±standard deviations. The value indicated by an asterisk (*) was significantly different from the invasion index of non-treated cells incubated in 20% O₂ (N=6). P values are indicated in the Examples section below.

FIG. 6 illustrates urokinase plasminogen activator receptor (uPAR) expression in MDA-MB-231 breast cancer cells. Western blot analysis of uPAR protein expression by cells incubated in 1% O₂ in the presence of various concentrations of glyceryl trinitrate (GTN) (A; N=3) or in 20% O₂ in the absence or presence of the NOS antagonist N-monomethyl-L-arginine (L-NMMA, 0.5 μM) alone or in combination with GTN (0.1 nM) (B; N=6). The effect of GTN (1 pM) on uPAR mRNA levels was also examined by Northern blot analysis of cells cultured under conditions similar as for the Western blots (C and D; N=3 and 6 respectively). In all cases, GTN was added at the beginning of the 24-h incubation period. 18S rRNA was used to assess uniformity of RNA loading in the Northern blots. Bars represent means of relative densities±standard deviations. Asterisks (*) indicate statistically significant differences as compared to control (20% O₂) values. All P values are indicated in the Examples section below.

FIG. 7 illustrates the effect of hypoxia on sGC activity and expression in MDA-MB-231 breast carcinoma cells. (A) Total cellular cGMP accumulated in MDA-MB-231 breast carcinoma cells cultured for 6-h in 20% O₂ or 0.5% O₂ in the presence or absence of GTN (1 μM). Cyclic GMP levels were measured and normalized to total protein levels. Values represent the mean of accumulated cGMP±standard deviation (N=3). (B) Western blot analysis of sGC expression in cells incubated for 24 hours in 20% O₂ or 0.5% O₂ (N=3). Bars represent the mean densities±standard deviations. Asterisks (*) indicate statistically significant differences compared to control (20% O₂) density values. P values for each condition are indicated in the Examples section below.

FIG. 8 illustrates the effect of sGC disruption on the NO-mediated inhibition of uPAR expression in MDA-MB-231 breast carcinoma cells. (A) Northern blot analysis of uPAR mRNA expression in cells cultured for 24 hours in 20% O₂ or 0.5% O₂, with or without GTN (1 μM) and the selective sGC inhibitor (ODG, 0.5 μM; N=5). (B) Northern blot analysis of uPAR expression in cells cultured for 24-h in the presence or absence of the heme disrupter DFO (100 mM), alone or in combination with GTN (1 μM) (N=5). Bars in both (A) and (B) represent mean relative densities±standard deviations. Values indicated by an asterisk (*) are significantly different. All P values are indicated in the Examples section below.

FIG. 9 illustrates the effect of 8-Br-cGMP on hypoxia- and DFO-induced uPAR expression in MDA-MB-231 breast carcinoma cells. (A) Northern blot analysis of uPAR expression in cells cultured for 24 hours in 20% O₂ or 0.5% O₂ in the absence or presence of various concentrations of 8-Br-cGMP (N=3). (B) Western blot analysis of uPAR protein in cells cultured for 24-h in 20% O₂ or 0.5% O₂ in the absence or presence of various concentrations of 8-Br-cGMP (N=9). (C) Northern blot analysis of uPAR transcript in cells cultured for 24-h in the absence or presence of DFO (100 μM) alone or with 8-Br-cGMP (1 μM) (N=6). Bars in (A), (B), and (C) represent mean relative densities±standard deviations. Values indicated by an asterisk (*) are significantly different from the control value (20% O₂). All P values are indicated in the Examples section below.

FIG. 10 illustrates the effect of PKG inhibition on uPAR expression in MDA-MB-231 breast carcinoma cells. (A) Northern blot analysis of uPAR expression in cells cultured for 6-h in the presence or absence of a PKG inhibitor (KT5823, 10 μM) (N=6). (B) Western blot analysis of uPAR protein levels in cells cultured for 6-h in the presence or absence of a PKG inhibitor (KT5823, 10 μM) (N=6). Bars represent mean relative density±standard deviation. Values indicated by an asterisk (*) are significantly different from the control value (20% O₂). All P values are indicated in the Examples section below.

FIG. 11 illustrates the effect of 8-Br-cGMP on the hypoxic upregulation of the in vitro invasiveness of MDA-MB-231 breast carcinoma cells. Cells were allowed to invade through a reconstituted extracellular matrix for 24-h in 20% O₂ or 0.5% O₂ in the absence or presence of varying concentrations of 8-Br-cGMP. The invasion index for each treatment was calculated after counting the cells that penetrated through the membrane. Values are presented as the relative mean of the invasion indices±standard deviation. The value indicated by an asterisk (*) was significantly different from the invasion index of the control (20% O₂) cells (N=6). All P values are indicated in the Examples section below.

FIG. 12 illustrates the effect doxorubicin (12.5-100 μM) on survival of human PC-3 prostate cancer cells. Cells were pre-exposed to 20% or 0.5% O₂ for 24 h before a 1 hr treatment with doxorubicin. Survival was assessed by clonogenic ability.

FIG. 13 illustrates the effect of a single dose of GTN on the hypoxia-induced resistance to doxorubicin. Treatment of (A) human PC-3 and (B) TRAMP-C2 cells with GTN (0.1 nM) prevented the acquisition of hypoxia-induced resistance to 12.5 μM doxorubicin over a 12 hour incubation in hypoxia. Results are presented as means±standard deviation (N=12). Single asterisk (*) indicates a statistically significant difference (P<0.0001) in survival compared with cells incubated in 20% O₂ at 12.5 μM doxorubicin. Double asterisk (**) indicates a statistically significant difference (P<0.0001) in survival compared with cells incubated in 0.5% O₂ alone.

FIG. 14 illustrates the effect of MDA-MB-231 human breast carcinoma cell spheroid culture on resistance to doxorubicin over time. Following initial cell plating, spheroids formed for 24, 48, 72, 96 or 120 h. At each time point, spheroids were exposed to 200 μM of doxorubicin, then disaggregated and plated for assessment of colony formation (survival). At this concentration of doxorubicin, survival in monolayer culture was zero (not shown).

FIG. 15 illustrates the effect of 200 μM doxorubicin in combination with the NO donor drug DETA/NO on MDA-MB-231 breast carcinoma spheroid cell survival. Spheroids were allowed to form for 72 h. DETA/NO was applied for the final 24 h of spheroid formation. Spheroids were then exposed to doxorubicin for 1 h, prior to disaggregation and plating for assessment of survival by clonogenic assay.

FIG. 16 illustrates the effect of GTN therapy on a patient with prostate cancer wherein the prostate is still intact. PSA levels in one patient with prostate cancer wherein the prostate is still intact are shown. This patient was administered three episodes of treatment, for approximately one month each, of GTN, 0.03 mg/hour, 24 hours a day. As shown, following commencement of the first two episodes, a decrease in the rate of increase in PSA levels was observed. Following commencement of the third episode, a decrease in PSA levels was observed.

FIG. 17 illustrates the effect of GTN therapy in combination with radiation therapy. Circulating PSA levels in one patient with prostate cancer wherein the prostate is still intact are shown. This patient was administered GTN chronically, transdermally at a concentration of 0.03 mg/hour. Two months after chronic GTN therapy was begun, the patient was administered radiation therapy. As shown, this combination therapy accelerated the rate of PSA decrease to within three months. The expected average for a similar decrease in PSA levels following radiation therapy alone is twelve months.

DETAILED DESCRIPTION OF THE INVENTION

We have now demonstrated that the mechanism by which hypoxia and hyponitroxia have impact on cellular phenotypes is not mediated solely due to a lack of oxygen, but rather also from a deficiency in nitric oxide mimetic activity. Further, we have now demonstrated that administration of a low dose of a nitric oxide mimetic is sufficient to increase, restore or maintain levels of nitric oxide mimetic activity of cells so that a malignant cell phenotype is inhibited or prevented. This inhibition and prevention occurs even when the cells are in a hypoxic environment and/or when combined with inhibition of endogenous nitric oxide production. Nitric oxide mimetics are effective under normoxic conditions as well as hypoxic conditions. Administration of very low doses of nitric oxide mimetics, even under conditions of markedly reduced levels of oxygen (1% O₂), was able to prevent the generation of a malignant cell phenotype and inhibit a malignant cell phenotype of cells.

Accordingly, the present invention relates to the use of nitric oxide mimetic (e.g., low dose) therapy in inhibiting and preventing a malignant cell phenotype of cells. The methods and formulations of the present invention provide new therapeutic approaches for the treatment and prevention of cancer in animals. For purposes of the present invention, by “treatment” or “treating” it is meant to encompass all means for controlling cancer by reducing growth of cells exhibiting a malignant cell phenotype and improving response to antimalignant therapeutic modalities. Thus, by “treatment” or “treating” it is meant to inhibit the survival and/or growth of cells exhibiting a malignant cell phenotype, prevent the survival and/or growth of cells exhibiting a malignant cell phenotype, decrease the invasiveness of cells exhibiting a malignant cell phenotype, decrease the progression of cells exhibiting a malignant cell phenotype, decrease the metastases of cells exhibiting a malignant cell phenotype, increase the regression of cells exhibiting a malignant cell phenotype, and/or facilitate the killing of cells exhibiting a malignant cell phenotype. “Treatment” or “treating” is also meant to encompass maintenance of cells exhibiting a malignant cell phenotype in a dormant (or quiescent) state at their primary site as well as secondary sites. Further, by “treating or “treatment” it is meant to increase the efficacy as well as prevent or decrease resistance to antimalignant therapeutic modalities. By “antimalignant therapeutic modalities” it is meant to include, but is not limited to, radiation therapies, thermal therapies, immunotherapies, hormone therapies, single agent chemotherapies, combination chemotherapies, chemo-irradiation therapies, adjuvant therapies, neo-adjuvant therapies, palliative therapies, and other therapies used by those of skill in the art in the treatment of cancer and other malignancies. “Treating” or “treatment” is also meant to encompass prolonged cancer remission, prevention of recurrence, decrease of cancer markers, reduction in cancer volume, reduction of pain, discomfort, and disability (morbidity), increase in quality of life associated with antimalignant therapeutic modalities, a decrease in mucositis, and a reduction in the need for anti-emetic agents and narcotic pain killers. By “increasing the efficacy”, it is meant to include an increase in potency and/or activity of the antimalignant therapeutic modality and/or a decrease in the development of resistance to the antimalignant therapeutic modality, and/or an increase in sensitivity of the malignant cells and/or tumor to the antimalignant therapeutic modality.

The present invention also relates to methods of monitoring and/or diagnosing malignant cell phenotypes in an animal via measurement of tumor selective markers in an animal in the presence of NO mimetic (e.g. low dose) therapy. Exemplary tumor markers useful in the monitoring and diagnosing of tumor progression and metastases include, but are not limited to, prostate specific antigen (PSA) for prostate cancer, carcinoembryonic antigen (CEA) and polypeptides such as gastrin and glucagon for gastrointestinal cancer, α-fetoprotein (AFP) and βhCG for testicular cancer, α-fetoprotein (AFP), human chorionic gonadotrophin (HCG) and lactate hydroginase (LDH) in germ cell cancers, HCG in choriocarcinoma, serum AFP in hepatocellular carcinoma, neuron-specific enolase (NSE) in small-cell lung cancer, paraprotein levels and B2-microglobulin which may be of prognostic value in myeloma, 5-hydroxyindole acetic acid (5HIAA) urine levels in carcinoid tumors, squamous cell carcinoma antigen (SCC) and cytokeratin fragments for squamous cell carcinoma, SCC and CA 125 for prognostic information in cervical carcinoma, CA19-9 and CA72-4 for gastric cancer, CD 24 for various cancers, including p-selectin ligand in non-small cell lung cancer, NFκB for prostate cancer prognosis, serum tumor marker CA125 for ovarian cancer, CDKN2A deletion as a diagnostic marker for malignant mesothelioma, dysadherin overexpression in pancreatic ductal adenocarcinoma, SMAD7 as a prognostic marker in patients with colorectal cancer, TGFβ1 as a potential prognostic marker for breast cancer patients with advanced disease, neuroendocrine and cytokeratin serum markers as prognostic determinants of small cell lung cancer, ErbB2 and bone sialoprotein as markers for metastatic osteosarcoma cells, cyclin E and CA15-3 for breast cancer and the cell surface receptors for estrogen and Her-2 for breast cancer. Additional markers which can be monitored for diagnostic purposes include, but are not limited to, calcitonin and calcitonin-related peptide for diagnosis and screening of medullary thyroid carcinoma, Protein Regulated by OXYgen-1 (PROXY-1), also known as NDRG-1, plasminogen activator inhibitor (PAI-1), urokinase-type plasminogen activator receptor (uPAR) and vascular endothelial growth factor (VEGF). Further, as will be understood by those of skill in the art upon reading this disclosure, additional tumor markers to those exemplified herein can also be monitored in the present invention. In a preferred embodiment, the tumor marker is detectable in a biological fluid such a serum, plasma or urine. No change, a decrease or deceleration in the increase of the level of one or more of these markers in an animal following administration of a low dose nitric oxide mimetic as compared to the level of the marker in the animal prior to administration of the low dose nitric oxide mimetic is indicative of a malignant cell phenotype in the animal.

For purposes of the present invention by the term “low dose” it is meant an amount of nitric oxide mimetic which is capable of increasing, restoring or maintaining a level of nitric oxide mimetic activity to cells, tumors and/or diseases which inhibits or prevents malignant cell phenotypes and/or which increases efficacy of an antimalignant therapeutic modality co-administered with the low dose NO mimetic. At this low dose, the known untoward effects of NO mimetics in animals without a malignant cell phenotype, cell, tumor and/or disease do not occur. As will be understood by those of skill in the art upon reading this disclosure, the nitric oxide mimetic increases, restores or maintains activity both in and around the cell (i.e. in the cellular microenvironment).

Methods for determining levels of nitric oxide of cells based upon nitrite, nitrate and S-nitrosothiol levels in cell culture, as well as plasma and serum, have been described. Serum or plasma nitrate levels in healthy normal volunteers have been reported to show a mean nitric oxide level of 33.4±8.9 μM with a range of 14 to 60 μM (Marzinzig et al. Nitric Oxide: Biology and Chemistry 1987 1(2): 177-189). These levels, however, are based on NO synthase end products, which accumulate and thus are likely to represent an overestimate of normal physiologic nitric oxide levels. Reported measured levels also vary depending upon the method selected for measurement. Further, levels of nitrite and nitrate in the plasma or serum are not solely representative of a patient's NO production. Based upon our experiments, we believe that normal physiologic levels of nitric oxide mimetic activity of cells may be lower, for example at least 5-fold, and preferably 10- to 10,000-fold lower, than those reported in the art, depending upon the cell.

Short-term nitric oxide mimetic therapy is generally administered at levels which increase nitric oxide mimetic activity of cells above normal physiologic levels. For purposes of the present invention, however, wherein longer-term therapy is generally desired, induction of tolerance against the NO mimetic and side effects become concerns. Thus, in certain aspects, the amount of nitric oxide mimetic administered is preferably very low so as to delay and/or reduce development of tolerance to the administered NO mimetic and/or unwanted side effects. For example, it is known that administration of nitric oxide or compounds which deliver nitric oxide to human beings at doses conventionally employed to treat cardiovascular conditions (i.e. GTN at 0.2 mg/h or greater) by vasodilation can provoke powerful vasodilator responses as well as development of drug tolerance against GTN upon repeated administration. Such administration is often accompanied by a number of undesirable side effects including headache, flushing and hypotension. In contrast, preferred doses of nitric oxide mimetic administered in the present invention to inhibit and prevent a malignant cell phenotype, cell, tumor and/or disease are lower, preferably at least 3 to 10,000-fold lower, more preferably at least 100- to at least 10,000-fold lower than those typically used in other therapeutic applications such as vasodilation and thus do not induce tolerance to the NO mimetic as quickly nor undesirable side effects. For example, using the nitric oxide mimetics sodium nitroprusside (SNP) and glyceryl trinitrate (GTN), we have now demonstrated that amounts ranging between 10⁻¹² and 10⁻¹⁰ M in the cellular environment can be used to prevent and inhibit a malignant cell phenotype, cell, tumor and/or disease. Further, based on results from these experiments, we believe that doses of SNP as low as 10⁻¹⁴ M would be effective in preventing and inhibiting a malignant cell phenotype, cell, tumor and/or disease in less hypoxic or hyponitroxic environments. Table 1 provides additional examples of various lower preferred doses for nitric oxide mimetics useful in the present invention as well as the comparative higher doses used in vasodilation therapy.

As will be understood by those of skill in the art upon reading this disclosure, lower or higher amounts of nitric oxide mimetics than those exemplified herein can also be administered based upon the efficacy of the nitric oxide mimetic in achieving the ultimate goal of increasing, restoring or maintaining nitric oxide mimetic activity of cells so that a malignant phenotype is prevented or inhibited without substantial drug tolerance to the NO mimetic developing and without unwanted side effects. Determining amounts of nitric oxide mimetic to be incorporated into the low dose formulations of the present invention can be performed routinely by those skilled in the art based upon the teachings provided herein.

By the phrase “inhibiting and preventing” as used herein, it is meant to reduce, reverse or alleviate, ameliorate, normalize, control or manage a biological condition. Thus, inhibiting and preventing a malignant cell phenotype in accordance with the present invention refers to preventing development, reversing or ameliorating development and/or normalizing, controlling or managing development of a malignant cell phenotype, cell, tumor and/or disease. Additionally inhibiting and preventing a malignant tumor in accordance with the present invention refers to preventing development, reversing or ameliorating development and/or normalizing, controlling or managing development of a malignant tumor. Similarly, inhibiting and preventing a malignant disease in accordance with the present invention refers to preventing development, reversing the ameliorating development and/or normalizing, controlling or managing development of a malignant disease. Accordingly, administration of a low dose of a nitric oxide mimetic can be used both (1) prophylactically to inhibit and prevent a malignant cell phenotype, cell, tumor and/or disease from developing in animals at high risk for developing cancer or exposed to a factor known to decrease nitric oxide mimetic activity of cells, and (2) to treat cancer in animals by inhibiting metastases and development of resistance to antimalignant therapeutic modalities and increasing the efficacy of antimalignant therapeutic modalities. According to Stedman's Medical Dictionary, malignant is defined as 1) Resistant to treatment; occurring in severe form, and frequently fatal; tending to become worse and lead to an ingravescent course; and 2) in reference to a neoplasm, having the property of locally invasive and destructive growth and metastasis. In accordance with this definition, for purposes of the present invention, by “malignant cell phenotype” it is meant to encompass increases in metastasis, resistance to antimalignant therapeutic modalities, and angiogenesis. By “malignant cell phenotype, cell, tumor and/or disease” for purposes of the present invention, it is also meant to be inclusive of conditions in the spectrum leading to malignant behavior and abnormal invasiveness such as hyperplasia, hypertrophy and dysplasia, as well as those cells and tissue that facilitate the malignant process. Examples of conditions in this spectrum include, but are not limited to, benign prostatic hyperplasia and molar pregnancy. As evidenced by data presented herein, inhibition and prevention of a malignant cell phenotype in cells, tumors and/or diseases can be routinely determined by examining expression of genes including, but not limited to, uPAR, PSA, PAI-1, PROXY-1 and VEGF, by examining cell invasiveness in in vitro or in vivo assays and/or by examining resistance of the cells to antimalignant therapeutic modalities. It is believed that elevated phosphodiesterase expression and/or activity may be observed in cells with a malignant cell phenotype. Methods for measuring expression of these genes have been described for example in WO 99/57306, which is herein incorporated by reference. As will be understood by those of skill in the art upon reading this disclosure, however, other methods for determining gene expression via measurement of expressed protein or proteolytic fragments thereof can also be used. For purposes of the present invention, by the term “nitric oxide mimetic” it is meant nitric oxide, or a functional equivalent thereof; any compound which mimics the effects of nitric oxide, generates or releases nitric oxide through biotransformation, generates nitric oxide spontaneously, or spontaneously releases nitric oxide; any compound which in any other manner generates nitric oxide or a nitric oxide-like moiety or activates other stages of the NO pathway; or any compound which enables or facilitates NO utilization by the cell, when administered to an animal. Such compounds can also be referred to as “NO donors”, “NO prodrugs”, “NO producing agents”, NO delivering compounds”, NO generating agents”, NO releasing agents, and “NO providers”. Examples of such compounds include, but are not limited to: organonitrates such as nitroglycerin (GTN), isosorbide 5-mononitrate (ISMN), isosorbide dinitrate (ISDN), pentaerythritol tetranitrate (PETN), erythrityl tetranitrate (ETN); amino acid derivatives such as N-hydroxyl-L-arginine (NOHA), N⁶-(1-iminoethyl)lysine (L-NIL), L-N⁵-(1-iminoethyl)ornithine (LN-NIO), N^(ω)-methyl-L-arginine (L-NMMA), and S-nitrosoglutathione (SNOG).

TABLE 1 Typical Vasodilatory and Low Doses of Organonitrate Compound Commercial Product Vasodilatory Dose Preferred Dose According to the Present Invention Nitroglycerin (sublingual tablets) Nitrostat ® (Parke-Davis); 0.3 mg, 0.4 mg Dissolve one tablet (0.3-0.6 mg) Dissolve one tablet containing from about 0.02 μg to and 0.6 mg sublingual tablets sublingually or in the buccal about 0.1 mg sublingually or in the buccal pouch pouch at the first sign of an acute anginal attack Nitroglycerin (lingual aerosol) Nitrolingual ® Spray (Rhone-Poulenc One or two metered doses (0.4-0.8 mg) About 0.02 μg to about 0.1 mg sprayed onto or under Rorer); metered aerosol, 0.4 mg/metered dose sprayed onto or under the the tongue tongue at the onset of an anginal attack Nitroglycerin (transdermal patch) Minitran ® (3M Corporation); Suggested dose is between 0.2-0.8 mg/h About 0.0125 μg/hr-0.1 mg/h Transdermal patches having the for 12-14 h daily with a following characteristics (size (cm²), minimum nitrate-free interval of delivery rate (mg/h)); (3.3, 0.1; 6.7, 0.2; 10-12 h 13.3, 0.4; and 20.0, 0.6) Nitroglycerin NITRO-BID ® Ointment (Hoechst Doses used in clinical trials have Ointment containing about 0.375 μg to about 3.75 mg (ointment) Marion Roussel); lactose and 2% ranged from ½ inch (1.3 cm; 7.5 mg); of nitroglycerin applied to the arms or legs over an nitroglycerin in a base of lanolin and to 2 inches (5.1 cm; 30 mg), area of about 36 square inches (232 cm²) white petrolatum. Each inch (2.5 cm), typically applied to 36 square as squeezed from the tube, contains approximately 15 mg inches (232 square cm) of skin on of nitroglycerin the arms or legs Isosorbide 5-mononitrate IMSO ® (Wyeth-Ayerst) 20 mg tablets 20 mg twice daily About 1 μg to about 2.5 mg twice daily Erythrityl tetranitrate Cardilate ® (Burroughs-Wellcome); Chronic (Adults): 10 mg orally 4 Chronic (Adults): About 0.5 μg to about 1.25 mg oral/sublingual tablets, 5 mg, 10 mg times daily, gradually increased to orally 4 times daily, gradually increased to about 1 μg 20 mg, if necessary, not to exceed to about 2.5 mg/day, if necessary, not to exceed about 100 mg/day. 5 to about 12.5 mg/day Sodium nitroprusside Nipride ® (Roche); Nitropress ® Slow infusion at a rate of 0.5 μg/kg/min Slow infusion at a rate of from 0.025 ng/kg/min to (Abbott); intravenous solution of a solution of 50 mg about 0.063 μg/kg/min of a solution of 50 mg in 500-1000 mL in 500-1000 mL of 5% dextrose of 5% dextrose up to a limit of about 0.18 mg/kg up to a limit of 3.5 mg/kg in brief to about 0.44 mg/kg in brief infusions infusions Molsidomine Corvaton ® (Hoechst Marion Roussel); 2 mg/day up to 36 mg/day given 0.1 μg/day up to 4.5 mg/day given in separate doses 2 mg, 4 mg, and 6 mg tablets in separate doses either twice or either twice or three times daily three times daily Nicorandil Nicorandil ® (Chugai Pharmaceuticals, For the treatment of angina 10-20 mg About 0.5 μg to about 1 mg twice daily twice daily Japan), Dancor ® (Merck) 10 mg, 20 mg tablets

NO prednisone and other compounds which generate or release NO under physiologic conditions such as S,S-dinitrosodithiol (SSDD), [N-[2-(nitroxyethyl)]-3-pyridinecarboxamide (nicorandil), sodium nitroprusside (SNP), S-nitroso-N-acetylpenicilamine (SNAP), 3-morpholino-sydnonimine (SIN-1), molsidomine, DEA-NONOate (2-(N,N-diethylamino)-diazenolate-2-oxide), and spermine NONOate (N-[4-[1-(3-aminopropyl)-2-hydroxy-2-nitrosohydrazino]butyl-1,3-propanediamine). Organic nitrates GTN, ISMN, ISDN, ETN, and PETN, as well as nicorandil (commonly known as a potassium channel opener) are commercially available in pharmaceutical dosage forms. SIN-1, SNAP, S-thioglutathione, L-NMMA, L-NIL, L-NIO, spermine NONOate, and DEA-NONOate are commercially available from Biotium, Inc. Richmond, Calif. As used herein the term “nitric oxide mimetic” is also intended to mean any compound which acts as a nitric oxide pathway mimetic, that has nitric oxide-like activity, or that mimics the effect of nitric oxide. Such compounds may not necessarily release, generate or provide nitric oxide, but they have a similar effect to nitric oxide on a pathway that is affected by nitric oxide. For example, nitric oxide has both cyclic GMP-dependent and cyclic GMP-independent effects. Nitric oxide is known to activate the soluble form of guanylyl cyclase thereby increasing intracellular levels of the second messenger cyclic GMP and other interactions with other intracellular second messengers such as cyclic AMP. As such, compounds which directly activate either particulate or soluble guanylyl cyclase such as natriuretic peptides (ANP, BNP, and CNP), 3-(5′-hydroxymethyl-2′ furyl)-1-benzyl indazole (YC-cGMP or YC-1) and 8-(4-chlorophenylthio) guanosine 3′,5′-cyclic monophosphate (8-PCPT-cGMP), are also examples of NO-mimetics. In some embodiments of the present invention, however, it is preferred that the NO-mimetic not encompass a compound which directly activates either particulate or soluble guanylyl cyclase. Nitric oxide mimetic activity encompasses those signal transduction processes or pathways which comprise at least one NO mimetic-binding effector molecule, such as for example, guanylyl cyclase and other heme containing proteins. Examples of agents which function as NO mimetics by enabling or facilitating NO utilization by the cell are compounds which inhibit phosphodiesterase activity and/or expression, such as phosphodiesterase inhibitors.

In a preferred embodiment of the present invention, more than one NO mimetic is administered. In this embodiment, it is preferred that the NO mimetics target or act upon different parts of the NO pathway of the cell. For example, an NO donor can be co-administered with a compound that inhibits cyclic nucleotide (e.g. cAMP or cGMP) degradation such as a phosphodiesterase inhibitor. Preferred phosphodiesterase (PDE) inhibitors useful as NO mimetics are those inhibiting PDE-1 through PDE-11.

By the term “hyponitroxia” in the present invention, it is meant conditions where levels of nitric oxide mimetic activity are lower than normal physiologic levels for that cell type.

Certain compounds suitable for use in the present invention are well known in the art and are described, e.g., in Goodman and Gilman, The Pharmacological Basis of Therapeutics (9th Ed.), McGraw-Hill, Inc. (1996); The Merck Index (12th Ed.), Merck & Co., Inc. (1996); The Physician's Desk Reference (49th Ed.), Medical Economics (1995); and Drug Facts and Comparisons, Facts and Comparisons (1993).

NO Donors

In preferred embodiments, the compounds of the present invention are NO donors. The nitric oxide donor can be any of a variety of NO donors including, for example, organic NO donors, inorganic NO donors and prodrug forms of NO donors. Additional suitable NO donors include compounds that can be metabolized in vivo into a compound which delivers nitric oxide (e.g., a prodrug form of a NO donor; a NO-releasing drug such as a NO-releasing non-steroidal anti-inflammatory drug (NO-NSAIDs), examples of which include nitro-aspirin, NCX 4016, nitro-(flurbiprofen), HCT 1026, NCX 2216; or a binary NO generating system, such as acidified nitrates), or compounds that serve as physiological precursor of nitric oxide, such as L-arginine and salts of L-arginine. The NO donor may include at least one organic nitrate (including esters of nitric acid) and can be either a cyclic or acyclic compound. For example, suitable NO donors include nitroglycerin (NTG), isosorbide dinitrate (ISDN), isosorbide mononitrate (ISMN) which may include isosorbide-2-mononitrate (IS2N) and/or isosorbide-5-mononitrate (IS5N), erythrityl tetranitrate (ETN), pentaerythritol tetranitrate (PETN), ethylene glycol dinitrate, isopropyl nitrate, glyceryl-1-mononitrate, glyceryl-1,2-dinitrate, glyceryl-1,3-dinitrate, butane-1,2,4-triol trinitrate, and the like. Nitroglycerin and other organic nitrates including ISDN, ETN, and PETN, have been given regulatory approval for use in treatments in other fields of medicine on human subjects. Additional NO donors include sodium nitroprusside, N,O-diacetyl-N-hydroxy-4-chlorobenzenesulfonamide, N^(G)-hydroxy-L-arginine (NOHA), hydroxyguanidine sulfate, molsidomine, 3-morpholinosydnonimine (SIN-1), (±)-S-nitroso-N-acetylpenicillamine (SNAP), S-nitrosoglutathione (GSNO), (±)-(E)-ethyl-2-[(E)-hydroxyimino]-5-nitro-3-hexeneamide (FK409), (±)-N-[(E)-4-ethyl-3-[(Z)-hydroxyimino]-5-nitro-3-hexen-1-yl]-3-pyridinecarboxamide (FR144420), and 4-hydroxymethyl-3-furoxancarboxamide. In addition, compounds that interfere with the breakdown of NO in vivo may be administered.

Additional NO Mimetics

In certain embodiments, the compounds and methods of the present invention are not limited to the foregoing traditional nitric oxide mimetics. As explained in detail below, these nitric oxide mimetics compounds include, for example, calcium channel blockers, α-adrenergic receptor antagonists and β-adrenergic receptor agonists, phosphodiesterase inhibitors, cAMP-dependent protein kinase activators, superoxide scavengers, potassium channel activators, benzodiazepines, adrenergic nerve inhibitors, antidiarrheal agents, HMG-CoA reductase inhibitors, adenosine receptor modulators, adenylyl cyclase activators, endothelin receptor antagonists, bisphosphonates, cGMP-dependent protein kinase activators, guanylyl cylase activators and SOC inhibitors. In certain aspects, the compounds are not limited to a low dose. Although a low dose can of course be used, the dosing of these compounds is not so limited. The compounds set forth below (e.g., PDE inhibitors) can be used at various doses such as high and low doses.

Calcium Channel Blockers

Ca²⁺ channel blockers are compounds that inhibit the entry of Ca²⁺ into the cell from the extracellular fluid. Suitable Ca²⁺ channel blockers for use with the methods of the present invention include, but are not limited to, nifedipine, nimodipine, felopidine, nicardipine, isradipine, amlodipine, diltiazem, bepridil, verapamil, etc. (see, e.g., WO 98/36733). L-type Ca²⁺ channel blockers are also available.

α-Adrenergic Receptor Antagonists and β-Adrenergic Receptor Agonists

Additional preferred compounds for use in the context of the present invention include, e.g., α-adrenergic receptor antagonists and β-adrenergic receptor agonists. Suitable α-adrenergic receptor antagonists include, for example, α₁-adrenergic receptor antagonists, α₂-adrenergic receptor antagonists and other nonspecific α-adrenergic receptor antagonists. Preferred α₁-adrenergic receptor antagonists include, but are not limited to, prazosin, doxazosin, phenoxybenzamine, phentolamine, terazosin, tolazoline, etc., and are described in Goodman and Gilman, “The Pharmaceutical Basis of Therapeutics,” 9th Edition, Hardman, et al. (ed.), McGraw-Hill (1996). Suitable α₂-adrenergic receptor antagonists include, but are not limited to, yohimbine and are also described in Goodman and Gilman, “The Pharmaceutical Basis of Therapeutics,” 9th Edition, Hardman, et al. (ed.), McGraw-Hill (1996). Other suitable antagonists are co-adrenergic antagonists include, for example, post-synaptic α₂-adrenergic antagonists. These post-synaptic α₂-adrenergic antagonists include, but are not limited to, imiloxan, ARC 239 dihydrochloride and other pharmaceutically acceptable salts thereof. ARC 239 dihydrochloride is 2-[2-(4-(2-Methoxyphenyl)piperazin-1-yl)ethyl]-4,4-dimethyl-1,3-(2H,4H)-isoquinolindone dihydrochloride. Other suitable post-synaptic α₂-adrenergic antagonists include, but are not limited to, idazoxan, rauwolscine, efaroxan, mianserin, and mirtazapine. Of these, mianserin and mirtazapine are particularly preferred. Suitable β-adrenergic receptor agonists for use with the methods of the present invention include, but are not limited to, β₁-adrenergic receptor agonists, β₂-adrenergic receptor agonists, β₃-adrenergic receptor agonists and other nonspecific β-adrenergic receptor agonists. In a preferred embodiment, the β-adrenergic receptor agonist is a β₂-adrenergic receptor agonist or a β₃-adrenergic receptor agonists. Examples of β-adrenergic receptor agonists suitable for use with the methods of the present invention include, but are not limited to, albuterol, bitolterol, salbutamol, terbutaline, metaproterenol, procaterol, salmeterol, clenbuterol, isoproterenol, zinterol, BRL 37344, CL316243, CGP-12177A, GS 332, L-757793, L-760087, L-764646, and L-766892, etc. (see, e.g., Goodman and Gilman, supra).

Phosphodiesterase Inhibitors

In another preferred embodiment, the compound is a phosphodiesterase inhibitor. Cyclic nucleotide second messengers (cAMP and cGMP) play a central role in signal transductions and regulation of physiologic responses. Their intracellular levels are controlled by the complex superfamily of cyclic nucleotide phosphodiesterases (PDE) enzymes. Inhibitors of phosphodiesterases (PDE) are agents that can either activate or suppress PDEs via allosteric interaction with the enzymes or binding to the active site of the enzymes. The PDE family includes at least 19 different genes and at least 11 PDE isozyme families, with over 50 isozymes having been identified thus far. The PDEs are distinguished by (a) substrate specificity, i.e., cGMP-specific, cAMP-specific or nonspecific PDEs, (b) tissue, cellular or even sub-cellular distribution, and (c) regulation by distinct allosteric activators or inhibitors. PDE inhibitors include both nonspecific PDE inhibitors and specific PDE inhibitors (those that inhibit a single type of phosphodiesterase with little, if any, effect on any other type of phosphodiesterase). Still other useful PDE inhibitors are the dual selective PDE inhibitors (e.g., PDE III/IV inhibitors or PDE II/IV inhibitors). Below is a table setting forth various PDE inhibitors that are useful in the methods of the present invention.

Isozyme Regulatory Selective Family Characteristics Inhibitors I Ca²⁺, Calmodulin-regulated Vinpocetine with different K_(m) values for cG and cA hydrolysis III CG-inhibited cA Milrinone, hydrolysis; low K_(m) for Amrinone, cA and cG Pimobendan, Cilostamide, Enoximone, Peroximone, Vesarinone IV Low K_(m) for cA hydrolysis Rolipram; RO-20-1724 V High and low Km isoforms Zaprinast; for cG specific Dipyridamole hydrolysis

In one embodiment, the PDE inhibitor is a PDE V inhibitor. Useful phosphodiesterase type V inhibitors include, e.g., cialis, vardenafil, tanadafil, zaprinast, MBCQ, MY-5445, dipyridamole, furoyl and benzofuroyl pyrroloquinolones, 2-(2-Methylpyridin-4-yl)methyl-4-(3,4,5-trimethoxyphenyl)-8-(pyrimidin-2-yl)methoxy-1,2-dihydro-1-oxo-2,7-naphthyridine-3-carboxylic acid methyl ester hydrochloride (T-0156), T-1032 (methyl 2-(4-aminophenyl)-1,2-dihydro-1-oxo-7-(2-pyridylmethoxy)-4-(3,4,5-trimethoxy-phenyl)-3-isoquinoline carboxylate sulfate), and sildenafil. Cyclic GMP specific inhibitors include but not limited to A02131-1 [3-(5′-hydroxymethyl-2′-furyl)-1-benzyl thieno (3,2-c)pyrazole] for example. In another embodiment, the composition contains a phosphodiesterase type II (PDE II) inhibitor such as, e.g., EHNA. In yet another embodiment, the composition contains a phosphodiesterase type IV (PDE IV) inhibitor. Suitable phosphodiesterase type IV inhibitors include, but are not limited to, roflumilast, ariflo (SB207499), RP73401, CDP840, rolipram, mesopram, denbufylline, EMD 95832/3, cilomilast, RO-20-1724, and LAS31025. In still another embodiment, the phosphodiesterase inhibitor is a dual selective phosphodiesterase inhibitor such as, e.g., a PDE III/IV inhibitor (e.g., zardaverine) or phosphodiesterase inhibitors which can increase both cAMP and cGMP levels such as Satigrel (E5510, 4-cyano-5,5-bis(4-methoxyphenyl)-4-pentenoic acid).

In another embodiment, the PDE inhibitor is an inhibitor of the PDE III isozyme, for example, Olprinone.

In another embodiment, the PDE inhibitor is an inhibitor of the PDE IV isozyme family, or cAMP-specific and rolipram sensitive PDEs, which preferentially hydrolyze cAMP.

In yet another embodiment, the composition contains an agent that is a nonspecific phosphodiesterase inhibitor. Suitable nonspecific phosphodiesterase inhibitors include, but are not limited to, theobromine, dyphylline, IBMX, theophylline, aminophylline, pentoxifylline, papaverine, caffeine and other methylxanthine derivatives.

cAMP-Dependent Protein Kinase Activators

In other preferred embodiments, the compound used to treat the disorders described herein is a cAMP-dependent protein kinase activator. Examples of cAMP-dependent protein kinase activators include cAMP mimetics or dual cGMP/cAMP-dependent protein kinase activators. Suitable cAMP mimetics or analogs include those compounds that are structurally similar to cAMP and that have similar functions e.g., activities, as cAMP. Examples of suitable cAMP mimetics include, but are not limited to, 8-bromo-cAMP, dibutyryl-cAMP, Rp-cAMPS, and Sp-cAMPS, and useful dual activators include compounds such as, e.g., Sp-8-pCPT-cGMPS, Sp-8-bromo-cGMPS and 8-CPT-cAMP.

Superoxide Scavengers

In another embodiment, the compound used in the compositions and methods of the present invention is a superoxide anion (O₂ ⁻) scavenger. Superoxide can react with NO and dramatically reduce its biological effects. Accordingly, agents that scavenge superoxide anions can enhance the effects of NO. Examples of superoxide scavengers include, but are not limited to, exogenous Mn or Cu/Zn superoxide dismutase (SOD) or small molecule SOD mimetics such as, e.g., Mn(III) tetra(4-benzoic acid) porphyrin chloride (MnTBAP) and M40403 (see, e.g., Salvemini, et al., Science. 286(5438):304-306 (1999)).

Potassium Channel Activators

In another aspect, the present invention provides pharmaceutical compositions comprising a potassium channel activator. In one embodiment, the potassium channel activator is an ATP-sensitive potassium channel activator. Synthetic compounds that activate ATP-sensitive K channels are smooth muscle relaxants. Such compounds include, but are not limited to, minoxidil, minoxidil sulfate, pinocidil, diazoxide, levcromokalim, cromokalim, etc. (see, e.g., White, et al., Eur. J. Pharmacol., 357:41-51 (1998)). Additional suitable ATP-sensitive K channel activators can be found in, e.g., Bristol, et al., “Annual Reports in Medicinal Chemistry,” Vol. 29, Chap. 8, pp. 73-82, Academic Press (1991). In another embodiment, the potassium channel activator is a Maxi-K channel activator. Examples of activators of the Maxi-K channels include, but are not limited to, estrogen-like compounds, such as estradiol (see, Valverde, et al., SCIENCE, 285:1929-1931).

Benzodiazepines

In another aspect, the present invention provides pharmaceutical compositions comprising a benzodiazepine. Suitable benzodiazepines include, but are not limited to, alprazolam, brotizolam, chlordiazepoxide, clobazam, clonazepam, chlorazepate, demoxepam, diazepam, estazolam, flumazenil, flurazepam, halazepam, lorazepam, midazolam, nitrazepam, nordazepam, oxazepam, prazepam, quazepam, temazepam, and triazolam (see, e.g., Goodman and Gilman, supra).

Adrenergic Nerve Inhibitors

In another aspect, the compounds of the present invention are compounds that inhibit adrenergic nerves. Adrenergic nerve inhibitors include compounds that destroy sympathetic nerve terminals, such as 6-hydroxydopamine and its analogs (see, e.g., Goodman and Gilman, supra). Adrenergic nerve inhibitors also include compounds that deplete norepinephrine storage, either by inhibiting norepinephrine biosynthesis or be depleting stores, and compounds that inhibit norepinephrine release. Compounds that inhibit norepinephrine biosynthesis include, but are not limited to, α-methyltyrosine. Compounds that deplete norepinephrine stores include, but are not limited to, reserpine, guanethidine and bretylium. Compounds that inhibit norepinephrine release include, but are not limited to, clonidine and other α₂-adrenergic receptor antagonists. Examples of sympathetic nerve terminal destroyers include, but are not limited to, α₂-adrenergic receptor antagonists.

Antidiarrheal Agents

In another aspect, the compounds of the present invention are antidiarrheal agents. Examples of suitable antidiarrheal agents include, but are not limited to, diphenoxylate, loperamide, bismuth subsalicylate, octreotide, etc. (see, e.g., Goodman and Gilman, supra).

HMG-CoA Reductase Inhibitors

In another aspect, the compounds of the present invention are HMG-CoA reductase inhibitors. Examples of HMG-CoA reductase inhibitors include, but are not limited to, mevastatin, lovastatin, simvastatin, pravastatin, cerivastatin, dalvastatin, atorvastatin, fluvastatin, etc. (see, e.g., Goodman and Gilman, supra).

Smooth Muscle Relaxants

In other embodiments, the compounds of the present invention are smooth muscle relaxants such as, e.g., hydralazine, papaverine, tiropramide, cyclandelate, isoxsuprine and nylidrin.

Adenosine Receptor Modulators

In another aspect, the present invention provides compositions for the treatment for a malignant cell phenotype comprising adenosine receptor modulators, either alone or in combination with another agent. Methods for the use of these compositions are also provided. In one group of embodiments, adenosine receptor modulators are used alone. In another group of embodiments, the adenosine receptor modulators are combined with at least one other muscle-relaxing agent. In other embodiments, the compounds of the present invention are adenosine receptor modulators such as methylxanthines. Examples of adenosine receptor modulators include theophylline and dyphylline. For other examples see, Goodman & Gilman, supra). Preferred agents are selected from those described with reference to the compositions of single agents or combinations above.

Theophylline, a plant-derived methylxanthine, has been used for the treatment of bronchial asthma for decades. Theophylline relaxes smooth muscle, notably bronchial muscle, that has been contracted experimentally with a spasmogen, or clinically in asthma. Proposed mechanisms of methylxanthine-induced physiologic and pharmacological effects include: 1) inhibition of phosphodiesterases, thereby increasing intracellular cyclic AMP, 2) direct effects on intracellular calcium concentration, 3) indirect effects on intracellular calcium concentrations via cell membrane hyperpolarization, 4) uncoupling of intracellular calcium increases with muscle contractile elements, and 5) antagonism of adenosine receptors.

A related compound, i.e., dyphylline, is a preferred adenosine receptor modulator. This compound is not metabolized by the liver and is excreted unchanged by the kidneys, therefore its pharmacokinetics and plasma levels are independent of factors that affect liver enzymes such as smoking, age, congestive heart failure, or the use of other drugs that affect liver function.

Adenylyl Cyclase Activators

In another aspect, the present invention provides compositions comprising adenylyl cyclase activators, either alone or in combination with other compounds or agents described herein. The adenylyl cyclase activator forskolin is preferred. Other examples of adenylyl cyclase activators, include, but are not limited to, N6, O2′-dibutyryl-cAMP, 8-chloro-cAMP, and Rp-diastereomers of adenosine 3′,5′-cyclic monophosphorothioate, and related analogs, such as Rp-8-bromo-adenosine 3′,5′-cyclic monophosphorothioate, and derivatives of forskolin, including colforsin daropate hydrochloride.

Endothelin Receptor Antagonists

In another aspect, the present invention provides compositions comprising endothelin receptor antagonist, either alone or in combination with other compounds disclosed herein. Examples of endothelin receptor antagonists include, but are not limited to, BE 1827B, JKC-301, JKC-302, BQ-610, W-7338A, IRL-1038, LRL-1620, bosetan, ABT 627, Ro 48-5695, Ro 61-1790, tesosentan (Ro 61-0612, ZD1611, BMS-187308, BMS-182874, BMS-193884, sitaxsentan (TBC 11251), TBC 2576, TBC 3214, TBC-10950, ABT-627, atrasentan, A-192621, A-308165, A-216546, CI-1020, EMD 122946, J-104132 (L753037), LU 127043, LU 135252, LU 302872, TAK-044 (69), SB 209670, SB 234551, SB 247083, ATZ1993, PABSA, L-749,329, RPR111723, RPR11801A, PD 164800, PD 180988 (CI1034), IRL 3630, IRL 2500, and their derivatives, etc. (see, Doherty, Annual Reports in Medicinal Chemistry, Volume 35, pp. 73-82, Academic Press, 2000). Other ethenesulfonamide derivatives, which are endothelin receptor antagonists and which are useful in the methods of the present invention, are disclosed by Harada, et al., Chem. Pharm. Bull., 49(12):1593-1603 (2001).

Bisphosphonates

In another aspect, the present invention provides compositions comprising bisphosphonates, either alone or in combination with other agents. Suitable bisphosphonates suitable for use in the methods of the present invention include, but are not limited to, alendronate sodium (Fosamax), pamidronate disodium (Aredia), etidronate disodium Ididronel) and the like.

cGMP-Dependent Protein Kinase Activators

In another aspect, the present invention provides cGMP-dependent protein kinase activators, either alone or in combination with other agents disclosed herein. Suitable cGMP-dependent protein kinase activators include, but are not limited to, cGMP mimetics or dual cGMP/cAMP-dependent protein kinase activators. Suitable cGMP mimetics or analogs include those compounds that are structurally similar to cGMP and that have similar functions, e.g., activities, as cGMP. Examples of suitable cGMP mimetics include, but are not limited to, 8-bromo-cGMP, dibutyryl-cGMP, Rp-cGMPS, and Sp-cGMPS, and useful dual activators include compounds such as, e.g., Sp-8-pCPT-cGMPS, Sp-8-bromo-cGMPS and 8-CPT-cAMP.

Guanylyl Cylase Activators

For example, BAY 41-2272 is a novel non-NO-based direct stimulator of soluble guanylyl cyclase that activates purified enzyme in a synergistic fashion with NO.

SOC Inhibitors

In another aspect, the present invention provides store-operated calcium influx (SOC) inhibitors, which inhibit calcium uptake into non-excitable cells in response to stimulus-mediated depletion of intracellular calcium storage pools. The SOC inhibitors preferably inhibit one or more of the following: calcium-dependent activation of nuclear factor of activated T cells (NFAT), nuclear factor kB (NF-kB), the stress kinase c-Jun N-terminal kinase (JNK) and exocytosis, resulting in the release or elaboration of inflammatory mediators. Examples of SOC inhibitors include for example statins in the δ-lactone form such as lovastatin, mevastatin, fluvastatin, pravastatin, dalvastatin, cerivastatin, atrovastatin and simvastatin.

Other treatment options include NO mimetics in combination with an antioxidant to further enhance efficacy. Such antioxidants include for example, lycopene, resveratrol, green tea polyphenolics (e.g. ECGC), brassinin (from cruciferous vegetables like Chinese cabbage), sulforaphane (from broccoli) and its analog sulforamate, withanolides (from tomatillos), and n-acetyl cysteine.

For purposes of the present invention by the term “animal” it is meant to include all mammals, and in particular humans. Preferably, NO mimetics are administered to an animal at risk for or suffering from a malignant cell phenotype. Such animals are also referred to herein as subjects or patients in need of treatment.

Low oxygen levels have been correlated with an increased level of cellular invasion and invasiveness. Hypoxic stress causes a variety of cellular adaptations, often manifesting in the up-regulation of certain genes.

For example, it has been shown that uPAR mRNA and cell surface uPAR protein levels increase under hypoxic conditions. uPAR is a high affinity cell surface receptor for pro-urokinase-type plasminogen activator (pro-uPA). Upon binding of pro-uPA to uPAR, the inactive single-chain pro-uPA is cleaved into its active, two-chain form. The activated enzyme, still attached to the receptor, then acts to convert plasminogen into plasmin, which ultimately degrades several components of the extracellular matrix (ECM). Active uPA also serves to activate both latent metalloproteinases and growth factors. uPAR also serves as a receptor for the ECM molecule vitronectin and can also modulate integrin function. In combination, these functions increase cellular invasion and potential for invasiveness. A positive correlation between hypoxia-induced uPAR up-regulation and carcinoma cell invasiveness has been suggested (Graham et al. Int. J. Cancer 1999 80:617-623). In addition, we have now shown hyponitroxia induced by administration of the nitric oxide synthase antagonist L-NMMA (0.5 mM) in hypoxic (1% O₂) and nonhypoxic (5% and 20% O₂) conditions to increase uPAR mRNA levels in human MDA-MD-231 cells incubated for 24 hours at 37° C.

Although the role of uPAR in invasion and tumor progression has been studied extensively, the regulatory mechanisms governing its expression are poorly understood. The invasive potential of a cell is highly dependent upon its ability to penetrate the extracellular matrix (ECM) and basement membranes that impede its movement. This process involves the participation of a number of proteolytic enzyme systems, of which the uPA system figures prominently. We postulate that the cGMP-dependent regulation of invasion and metastasis seen the current study was at least partially mediated through alterations in uPAR expression.

We suggest a novel mechanism of oxygen sensing and uPAR regulation whereby phenotypes are modified in response to a decrease in cGMP-dependent signaling. This phenomenon is due to a reduction in endogenous NO synthesis. Molecular oxygen is obligatory for the conversion of L-arginine into NO and L-citrulline by the enzyme NO synthase (NOS). Indeed, exposure of cells to low levels of oxygen (1-3%) inhibits NO production by up to 90% and NOS inhibition has been shown to induce invasive phenotypes in a manner similar to hypoxia. Due to the reduced NO levels, there is a decrease in GC activity and a consequential reduction in cellular cGMP. Indeed, Taylor et al. (1998) showed that culturing intestinal epithelial cells in hypoxia (1% O₂; 24 Hrs) resulted in a significant decrease in basal and stimulated cGMP levels. Our studies have also suggested that a potential oxygen sensing mechanism of epithelial cells involves the participation of heme containing proteins such as GC. We have similarly shown that low oxygen levels decrease cGMP generation, and that they also result in phenotypic alterations. In both studies, these alterations were overcome by the addition of 8-Br-cGMP. We have further shown that inhibition of soluble guanylyl cyclase (sGC) with 1H-[1,2,4]Oxadiazole[4,3-a]quinoxalin-1-one (ODQ) can antagonize the ability of NO-mimetics to prevent the hypoxic up-regulation of uPAR. Given these findings we have derived a working model for the oxygen-mediated regulation of uPAR (FIG. 4). In this model, low oxygen levels result in decreased NO synthesis and a consequential decrease in sGC activation. As such, cellular cGMP levels are lowered, resulting in decreased PKG activity.

One possible mechanism involves a perturbation of the MAP kinase signaling pathway. This pathway is activated by hypoxia and studies have shown that NO can prevent the phosphorylation of ERK through a PKG-mediated interference of RAS/Raf. This concept has been strengthened by Yoshihide et al. (2000) who showed that NO donors and cGMP mimetics could reduce elastase levels by suppressing ERK phosphorylation. This led to a subsequent reduction in the activation and DNA binding capacity of AML1B (the transcription factor for elastase). It is possible that cGMP-dependent NO signaling similarly inhibits hypoxia-induced ERK phosphorylation, thereby decreasing the activation of the transcription factors responsible for the up-regulation of uPAR.

The promotor region of uPAR contains binding sites for transcription factors such as activator protein-1 (AP-1), Sp-1/3 and nuclear factor κB (NFκB). Hypoxia Inducible Factor 1 (HIF-1) levels may also contribute to the transcriptional activation of the uPAR gene, as previous examination of the sequences upstream of the uPAR initiation codon revealed the presence of at least 3 potential HIF-1-binding sites. It has also been shown that HIF-1 accumulation and transcriptional activity can be reduced by relatively high concentrations (2.5-500 μM) of NO mimetics such as SNP, S-nitroso-L-glutathione and 3-morpholinosydnonimine. Preliminary studies in our laboratory have confirmed that high concentrations (0.1-1 mM) of GTN and SNP inhibit HIF-1 accumulation and transactivating activity. However, concentrations of the NO mimetics that completely inhibited the hypoxic stimulation of metastasis, invasiveness and uPAR expression had no effect on HIF-1 accumulation or transactivating activity under hypoxia. Similarly, the administration of 8-Br-cGMP did not affect HIF-1 activity. Therefore it is unlikely that the cGMP-dependent regulation of invasive phenotypes is mediated via alterations in HIF-1.

Like uPAR, PAI-1 has also been shown to be stimulated under hypoxic conditions. See WO99/57306. Further, this stimulation was accompanied by a decrease in cellular adherence. PAI-1 is 52-kDa ECM glycoprotein which is produced by a variety of normal and malignant cells. This glycoprotein is a regulator of plasminogen activator activity. It functions to inhibit both free and bound uPA through the formation of irreversible covalent complexes. PAI-1 has also been shown to compete with the uPAR for binding to the same domain of vitronectin. As such, PAI-1 is capable of releasing cells bound to vitronectin-coated plates. Studies have shown that PAI-1 is required for the optimal in vitro invasiveness of lung carcinoma cells.

Hypoxia has also been shown to increase the resistance of cells to cytotoxic agents. The gene for PROXY-1 was identified using an RT-PCR based differential display following the culture of a variety of cell types under low levels of oxygen. See WO99/57306. It is believed that the 43-kDa PROXY-1 protein plays a role in protecting cells from insults including hypoxia, DNA damaging agents, cytotoxic agents and glucose deprivation, as enhanced PROXY-1 expression is observed in response to each of these harmful stimuli. Together with the fact that this gene is expressed by a variety of unrelated cell types, this type of gene expression is indicative of PROXY-1 being a universal ‘switch’ involved in the initial events that lead to cellular adaptations to hypoxia.

However, it is possible that the role of NO in tumor cell initiation, promotion, progression, survival and apoptosis depends on the cell types, the concentrations of NO in the given cellular microenvironment, time of cellular exposure to NO, and possibly other factors. A similar paradigm has been drawn from the role of NO in acute and chronic inflammatory processes and in myocardial and neuro-protective preconditioning, for example. As a plieotropic transcriptional factor, NFκB (nuclear factor kappa B)-induced antiapoptotic signals have been suggested to be responsible for the development of chemoresistance in various forms of cancer, in tumor progression, and in the development of radiation resistance. NF-κB as a molecular target for developing anti-cancer therapy has been reviewed extensively by several investigators. Various known NFκB inhibitors such as NSAIDs, glucocorticoids, COX 2 inhibitors, and more recently proteasome inhibitors (blocks NF-κB activation), have been shown to be effective or potentially effective cancer treatment options. Known NFκB inducible genes that may be involved in tumor progression and chemoresistance include VEGF (vascular endothelium growth factor), EGFR (epidermal growth factor receptor), COX2 (cyclooxygenase type 2), MMPs (matrix metalloproteases 2 and 9 for example), uPAR (urokinase plasminogen activator receptor), etc. In a recent review article on inflammation and cancer, anti-inflammatory therapy is considered an efficacious approach towards early neoplastic progression and malignant conversion

It is possible that NO may function as the feedback inhibitor of NFκB upregulation/activation. Alternatively, NO may affect p53 tumor suppressor gene expression, or BcL expression. It is also possible that NO may enhance chemosensitivity of tumor cells via a completely unknown mechanism. While the traditional approach to treat cancer with combination chemotherapeutic agents and/or radiation therapy is primarily based on the known mechanism of action, current approach focuses on the balancing the effectiveness of the treatment and toxicity profile of selected drugs. Since many of the NO mimetics are proven to be safe for both acute and chronic usage, it presents as a unique opportunity to minimize the safety risk when NO mimetics is added to the known standard of treatments of various forms of cancer.

In some forms of cancer, for example, prostate and breast cancers, hormonal therapy is typically used for early phase of the diseases. Hormonal therapy includes anti-androgens (e.g. flutamide) for prostate cancer and anti-estrogen (e.g. tamoxifen) for estrogen receptor positive or ER status unknown early stage breast cancers. In general, the tumor responded well to the hormonal therapy before a new phenotype is developed. The newly developed phenotypes are typically no longer responding to the original hormonal therapy; prognosis for patients at this stage of cancer, i.e. hormone refractory/insensitive phase is typically very poor. Even while using hormonal therapy during the hormone responding phase of cancers, patients suffer from hot flashes, loss of libido, sexual dysfunction, osteopenia, osteoporosis, poor self-esteem and quality of life. The mechanism leading to the loss of hormone response of these cancer phenotypes are largely unknown at this point. It could be related to androgen/estrogen receptor expression levels, cellular locations, functional activities of these steroid receptors. Alternatively, it could also due to the altered non-genomic actions of these steroid targets at various cellular compartments and sub-compartment, e.g. mitochondria.

Endogenous androgens including testosterone and 5-α-dihydrotestosterone (DHT; one of the two key metabolites of testosterone) are essential for the development and maintenance of reproductive tissues (e.g. testis, epididymis, seminal vesicles, penis, etc.) in male species. Exogenously administered androgens, e.g. testosterone undecanoate, testosterone propionate, etc. typically transformed to testosterone or DHT before exerting its biological activity. The majority of the biological activities of testosterone and DHT are elicited by the cytosolic androgen receptor (AR). The AR is a member of the steroid hormone-thyroid hormone-retinoic acid nuclear receptor super-family. Upon androgen binding, the AR undergoes conformational changes resulting in the release of inhibitory proteins and is subsequently hyper-phosphorylated, translated to the cell nucleus. Once in the nucleus, AR is dimerized and binds to hormone response elements in the regulatory regions of androgen target genes, and subsequent gene transcriptional events. DHT binds to AR with higher affinity and induces a higher level of androgen-regulated gene expression than testosterone. Since the second key metabolite is E₂, the biological activity of testosterone is also mediated at least in part, by the activation of estrogen receptor.

Evidence has been recently obtained for ligand-independent activation of AR transcriptional activity by peptide growth factors, such as IGF-I (insulin-like growth factor), and to a lesser extent, keratinocyte growth factor and epidermal growth factor. Like other steroid receptor ligands, testosterone can also elicit biological activities via non-genomic mechanisms that often involve ion fluxes in androgen-dependent cell types. Specifically, calcium fluxes following addition of picomolar concentrations of testosterone have been reported in rat heart myocytes, male rat osteoblasts, human prostate cancer cells, and Sertoli cells. Direct evidence from patch-clamp studies showed that testosterone can open K⁺-channels in single coronary myocytes. Although testosterone mediated ion fluxes have been reported in various cell types, the biological consequences of these activities are still poorly defined.

While infrequent in early and localized prostate tumors, mutations of the AR have been identified in a number of advanced prostatic cancers. Substantial evidence suggests that AR activity is enhanced in advanced forms of prostate cancer, and in some cases, as a result of gene amplification events. Frequently, the AR also appears to have altered ligand specificity; for example, advanced prostate cancers often become androgen-independent, and no longer respond to androgen ablation therapy. The loss of androgen-sensitivity is considered an indicator of poor prognosis for advanced prostate cancers.

NO mimetics may be able to maintain the tumor cell under homeostatic stage, thus prevent the alteration of steroid receptor expressions, levels of expression, location, or alternatively, the ion-channels related to androgen and anti-androgen action etc. Thus, the administration of NO mimetics could keep patients under hormonal therapy for various forms of cancer under hormone responsive phase, preventing or delaying metastasis to secondary sites and transformation to more advanced, hormone-refractory/insensitive/insensitive cancers. NO mimetics can be administered in conjunction with hormonal therapy during the treatment phase and/or can be used in the remission phase.

In certain cases, NO mimetics can be used with chemo- and/or radio-therapeutic treatment to ensure eradication of cancers during the treatment phase, and can be used as stand-alone therapy during the remission. If low dose of chemotherapy is employed to prevent cancer recurrence, NO mimetics can be used with the low dose chemotherapy to prevent or prolong the time to cancer recurrence and eventually, prolong the survival time of cancer patients. The addition of NO mimetic therapy could also 1) reduce the dependence on narcotic pain relief agents and thus associated adverse events due to their use and yet enhance the effectiveness of these agents, 2) prevent progressive lost of bone mineral density and thus, the development of osteoporosis and the risk of bone fracture, and 3) improve overall quality of life of cancer suffers.

We have now found that nitric oxide is a primary mediator of cellular adaptive responses to changes in oxygen levels in and around the cell. Through administration of a low dose of a nitric oxide mimetic, we have shown that nitric oxide mimetic activity can be increased, restored or maintained at a level which inhibits or prevents a malignant cell phenotype. In contrast, the effect of maintaining low oxygen levels on cells was limited to inhibiting basal levels of endogenous nitric oxide production.

Under hypoxic conditions where the levels of oxygen are limiting, we have now demonstrated that cancer cell lines acquire one or more of the following malignant cell phenotypic properties: they increase their lung-colonization ability following i.v. inoculation into syngeneic mice (experimental metastasis); they increase their invasiveness through the extracellular matrix in vitro (also relevant to metastasis); and they become more resistant to the chemotherapeutic drug doxorubicin and 5-fluorouracil. In these experiments, cancer cells were exposed to 1% O₂ (10-15 mmHg pO₂) to induce hypoxia and compared with nonhypoxic cancer cells exposed to 5-20% O₂ (30-160 mmHg). By administering low doses of nitric oxide mimetics (during periods when oxygen levels are limiting and/or when endogenous nitric oxide production is inhibited) acquisition of these malignant phenotypic changes is prevented. This prevention occurs even when the cells are in an extremely hypoxic environment.

We have now demonstrated that low concentrations of nitric oxide mimetics SNP and/or glyceryl trinitrate (GTN) inhibit the hypoxic up-regulation of uPAR and PAI-1, as well as PROXY-1. Similar low dose nitric oxide mimetic therapy is expected to also be effective in inhibiting hyponitroxic upregulation of these genes such as that observed in cells treated with L-NMMA (0.5 mM), i.e. inhibiting and preventing a malignant cell phenotype.

Experiments performed in human breast cancer cells cultured in hypoxic conditions (1% O₂) showed that treatment of the hypoxic cells with 10⁻¹²M SNP significantly reduced levels of uPAR mRNA as compared to untreated control hypoxic cells and hypoxic cells treated with 10⁻⁸ M SNP. Similarly, treatment of breast cancer cells cultured in hypoxic conditions with the nitric oxide mimetic GTN at low doses of 10⁻¹¹ M and 10⁻¹⁰ M significantly reduced uPAR mRNA levels in the hypoxic cells as compared to untreated hypoxic cells and to hypoxic cells treated with GTN at 10⁻⁹ M, 10⁻⁸ M, 10⁻⁷M, 10⁻⁶M and 10⁻⁵ M. In fact, levels of uPAR mRNA in hypoxic breast cancer cells treated with 10⁻¹¹ M GTN and 10⁻¹⁰ M GTN were similar to levels of uPAR mRNA measured in cells cultured under non-hypoxic conditions (20% O₂). Levels of uPAR mRNA in hypoxic cells treated with GTN at 10⁻⁶M and 10⁻⁵ M were similar to levels of untreated hypoxic cells, suggesting tolerance to the NO mimetic. A reduction in uPAR protein levels was also observed in these cells 24 hours after incubation with these nitric oxide mimetics.

Further experiments with human invasive trophoblast cells (HTR-8/SVneo) confirmed the ability of low doses of these nitric oxide mimetics to decrease expression of uPAR in hypoxic cells.

The effects of treatment of HTR-8/SVneo invasive trophoblast cells with the nitric oxide mimetic GTN on PROXY-1 mRNA levels was also examined. PROXY-1 mRNA levels were very low in cells cultured in 20% O₂. However, levels of PROXY-1 mRNA were increased in cells cultured in 1% O₂ which were untreated or treated with 10⁻⁷ M GTN. In comparison, levels of PROXY-1 were much lower in hypoxic cells treated with a low dose, 10⁻¹¹ M GTN.

In addition, the effects of the nitric oxide mimetics SNP and GTN on PAI-1 mRNA levels in breast cancer cells were examined. Again, treatment of hypoxic cells with low doses of the nitric oxide mimetics SNP (10⁻¹² M) and GTN (10⁻¹¹ M) significantly decreased levels of PAI-1 mRNA as compared to untreated hypoxic cells.

Experiments were also performed to ascertain the effects of low doses of nitric oxide mimetics on levels of metalloproteinase. Breast cancer cells were incubated in hypoxic or control conditions in the presence of varying concentrations of SNP or GTN. Treatment of hypoxic cells with low doses, 10⁻¹¹ M GTN and 10⁻¹² M SNP, of a nitric oxide mimetic resulted in a decrease in gelatinases secreted from the cells as compared to untreated hypoxic cells.

Functionally, inhibition of the hypoxic up-regulation of these genes was then shown to result in a decrease in cellular invasiveness and drug resistance. The invasive ability of cells in hypoxic conditions in the presence or absence of nitric oxide mimetics was also assessed using Matrigel invasion chambers (modified Boyden chambers). In these in vitro invasion assays, either breast cancer cells (see FIG. 1) or HTR-8/SVneo invasive trophoblasts were plated on Matrigel-coated membranes. Cells were then incubated under hypoxic or normal conditions, alone or in the presence of nitric oxide mimetics. The invasion index for each treatment was determined by staining the cells which invaded through the membrane and counting them. In both cell lines, treatment with low doses of nitric oxide mimetics significantly reduced hypoxic cell invasiveness as compared to untreated hypoxic cells. The invasive indices of hypoxic breast cancer cells treated with 10⁻¹⁰ M SNP and 10⁻¹¹ M GTN were similar to or even lower than cells cultured under non-hypoxic conditions. In HTR-8/SVneo trophoblast cells, 10⁻⁷ M GTN inhibited invasiveness of hypoxic cells by 56.2%, while 10⁻⁸ M SNP inhibited invasiveness by 63.4%.

The ability of low doses of nitric oxide mimetics to inhibit metastases of tumor cells in animals was then confirmed. In a first set of experiments, the ability of hypoxic conditions to increase number of metastases was demonstrated. In these experiments, mice were administered via tail vein injection a bolus of metastatic melanoma cells. Immediately after injection the mice were divided into two groups. The first group was placed in a chamber with a continuous flow of a gas mixture comprising 21% O₂ (room air). The second group was placed in a hypoxic environment with only 10% O₂. After 24 hours, both groups were removed and placed in regular cages kept at room air. After 14 days, the animals were sacrificed and metastatic nodules in the lungs of the animals were counted. Animals in the hypoxic environment had a 2-fold statistically higher number of lung nodules as compared to animals in the non-hypoxic environment.

In a second set of experiments, mice were injected with mouse melanoma cells which were pre-incubated for 12 hours in 1% or 20% O₂ in the presence or absence of a low concentration of a nitric oxide mimetic (GTN; 2×10⁻¹¹ M). After fourteen days, the mice were sacrificed and the lungs were visually observed for metastatic nodules. In addition, the number of lung nodules in these mice was compared. Lungs of animals that had been administered hypoxic and non-hypoxic melanoma cells treated with the nitric oxide mimetic prior to injection exhibited statistically less metastatic nodules as compared to animals administered either untreated hypoxic and non-hypoxic melanoma cells (see FIG. 2). Specifically, the in vitro pre-treatment with 2×10⁻¹¹ M GTN decreased the hypoxia-stimulated lung nodule formation by 85% and, even in 20% oxygen, the GTN pre-treatment reduced the extent of metastasis by more than 60%. In fact, the suppression of lung nodule formation by GTN pre-treatment was found to be equivalent regardless of the in vitro oxygenation levels. Further, treatment of the cells with L-NMMA prior to inoculation into mice resulted in a 63% overall increase in the number of lung nodules (p<0.01; post hoc Fisher's test). Concomitant treatment using GTN (10⁻¹⁰ M) and L-NMMA attenuated this metastatic response by 60% (p<0.0005). The frequency distribution of lung nodules across the three experimental groups ranged from 0 to 111. No lung nodules were found in two of the control mice and four of the GTN-treated mice. Characterization of the lung nodule frequency by tertile revealed a consistent pattern of suppression throughout the NO-mimetic treated group compared to the L-NMMA treated group. In addition, the metastasis in the GTN-treated group was significantly below even the control levels in the highest tertile. Taken together, these data indicate that the levels of NO, and not oxygen itself, determine the severity of the metastatic phenotype. Further, the effect of low-concentration GTN treatment on lung nodule formation was not due to a non-specific cytotoxic or growth inhibitory effect on the cells as they had similar in vitro colony-forming ability as untreated cells.

As will be understood by those skilled in the art upon reading this disclosure, results from the studies in this murine model can be used to predict drug disposition in other species including humans, to define pharmacokinetic equivalence in various species including humans and design dosing regimes for other experimental animal models and for human clinical studies. Such pharmacokinetic scaling is performed routinely based upon data such as provided herein as evidenced by references such as Mordenti, J. J. Pharm. Sci. 1986 75(11):1028-1040.

Further, the ability of an NO mimetic to reduce disease progression in humans was demonstrated. In this study, continuous transdermal patches were used to deliver very low doses of GTN (0.033 mg/hour) to patients with recurrent prostatic adenocarcinoma. Patients with prostatic adenocarcinoma were selected for this study because the progression of this type of cancer correlates well with the plasma levels of prostate-specific antigen (PSA). Thus, the outcome of low dose NO mimetic therapy can be easily assessed by measuring PSA levels. Analysis of data from two patients in this study revealed a sharp decline in plasma PSA levels within two months of GTN treatment, thus indicating low dose NO mimetic therapy to be an effective approach to the management of cancer, particularly prostate cancer, in humans (see FIGS. 3A and 3B). Plasma PSA levels were measured via a commercially available immunoassay kit such as Immuno 1 (Bayer Corporation).

The ability of low doses of nitric oxide mimetics to decrease resistance of breast cancer cells to doxorubicin was also examined. In these experiments, the ability of hypoxic conditions to increase resistance to doxorubicin was first confirmed. Cells exposed to 1% O₂ had higher survival rates at concentrations of 25 and 50 μM doxorubicin as compared to cells exposed to 20% O₂. The effect of low doses of the nitric oxide mimetic GTN on doxorubicin resistance of hypoxic and non-hypoxic cells was then examined. It was found that hypoxic cancer cells treated with 10⁻⁶ M and 10⁻¹⁰ M GTN had lower doxorubicin survival rates as compared to untreated hypoxic cells. The survival rates of the nitric oxide mimetic treated hypoxic cells were comparable to those observed in untreated non-hypoxic cells and non-hypoxic cells treated with the nitric oxide mimetic. These results have been confirmed in multiple human cancers as well as mouse cancers and with other antimalignant therapeutic modalities.

Thus, these studies demonstrate that a malignant cell phenotype such as that induced by hypoxia can be inhibited and prevented by increasing (restoring) the level of nitric oxide mimetic activity. Other factors known to lower cellular nitric oxide mimetic activity so as to induce a malignant cell phenotype include, but are not limited to, decreases in arginine levels, exposure to endogenous nitric oxide synthase antagonists such as L-NMMA and ADMA, exposure to endogenous nitric oxide scavengers such as superoxide, changes in nitric oxide synthase expression, changes in cofactors such as GSH and NADPH, glucose deprivation, surgical procedures, administration of anesthetic agents, administration of pharmacologic agents which alter circulation such as, but not limited to antihypertensive agents, and traumatic injuries including, but not limited to those associated with blood loss, decreased blood volume, and hemorrhage. The present invention relates to methods of inhibiting and preventing a malignant cell phenotype resulting from these and other factors by administering low doses of one or more nitric oxide mimetics.

The low dose nitric oxide mimetic therapy of the present invention will also prevent the malignant cell phenotype of vascular endothelial cells which ultimately results in recruitment of such cells by a tumor and development of a blood supply to the tumor, also known as angiogenesis. Attempts at cutting off tumor blood supply by blocking VEGF in vascular endothelial cells have been relatively unsuccessful as cancer treatments. The presence of VEGF in tumors has been shown to suppress tumor invasiveness. Thus, it is believed that agents which remove or block the actions of VEGF, such as anti-VEGF antibody, actually generate more aggressive cancer cell phenotypes. Using the present invention, however, generation of a more aggressive malignant cell phenotype can be prevented, thereby allowing use of anti-VEGF therapies to prevent angiogenesis without producing more aggressive cancer cells.

These studies also demonstrate the ability of low dose NO mimetic therapy to decrease levels of a tumor marker in a patient. Tumor marker levels are used routinely by those of skill in the art as indicators of the progression of a cancer. Accordingly, the ability of low dose NO mimetic therapy to decrease levels of these markers is indicative of its ability to treat cancers. Further, progression of a tumor can be diagnosed and/or monitored in a patient by measuring the levels of a tumor marker in the patient in the presence of a low dose of a nitric oxide mimetic.

Low dose formulations of nitric oxide mimetics which ultimately result in an increase, restoration or maintenance of nitric oxide mimetic activity of cells sufficient to prevent or inhibit a malignant cell phenotype can be produced in accordance with formulation methods known in the art. Formulations for the administration of nitric oxide mimetics in accordance with the method of the present invention can take the form of ointments, transdermal patches, transbuccal patches, injectables, nasal inhalant forms, spray forms for deep lung delivery through the mouth, orally administered ingestible tablets and capsules, and tablets or lozenges, or “lollipop” formulations for administration through the oral mucosal tissue. The latter formulations included tablets, lozenges and the like which are dissolved while being held on or under the tongue, or in the buccal pouch. It is preferred that the pharmaceutical preparations provide a low dose of the nitric oxide mimetic sufficient to increase, restore or maintain nitric oxide mimetic activity at a level which inhibits or prevents a malignant cell phenotype, also referred to herein as a therapeutically effective amount, during the period in which cellular nitric oxide mimetic activity of cells is lowered. Also preferred are formulations comprising more than one NO mimetic. In this embodiment, it is preferred that the NO mimetics target or act on different parts of the NO pathway. For example, an NO donor can be co-administered with a compound that inhibits cyclic nucleotide (e.g. cAMP or cGMP) degradation such as a phosphodiesterase inhibitor. Preferred phosphodiesterase (PDE) inhibitors useful as NO mimetics are those inhibiting PDE-1 through PDE-5.

While the methods of the present invention are useful for treating a broad range of diseases, they are particularly effective for lung cancer, including non-small cell lung cancer and small cell lung cancer; mesothelioma; thymic tumors; breast cancer, such as ductal carcinoma in situ, lobular carcinoma in situ, ductal carcinoma of special type, and invasive lobular carcinoma; colorectal cancer; anal cancer; esophageal cancer; gastric cancer; small intestine and carcinoid tumors; cancers of the liver such as primary liver cancer and hepatocellular carcinoma; cancer of the biliary tract, including cholangiocarcinomas; tumors of the gall bladder; pancreatic cancer; endocrine cancers such as thyroid cancer, adrenal cancer, and neuroblastoma; genitourinary cancers such as renal cancer, Wilms' tumor, cancer of the bladder and ureter, prostate cancer, and testicular cancer; gynecological cancers such as ovarian cancer, cancer of the uterine corpus, cancer of the cervix, vaginal and vulvar cancer, and trophoblastic tumors; head and neck cancer such as cancer of the larynx, cancer of the oral cavity, carcinoma of the nasopharynx, cancer of the nasal cavity and paranasal sinuses, cancer of the eye and orbit, and salivary gland tumors; tumors of the central nervous system such as primary brain tumors and brain metastatses; skin cancer, including primary cutaneous malignant melanoma and non-melanoma skin cancers; hematological malignancies including acute leukemia, chronic lymphoid leukemias, Hodgkin's disease, non-Hodgkin's lymphomas, and myeloma; bone and soft tissue malignancies such as osteosarcoma, Ewing's sarcoma, other primary bone tumors, and soft tissue sarcomas; cancer of unknown primary site; paraneoplastic syndromes, including endocrine paraneoplastic syndromes, neurological paraneoplastic syndromes, hematological paraneoplastic syndromes, and dermatological paraneoplastic syndromes; and AIDS-related malignancies, including Kaposi's sarcoma, non-Hodgkin's lymphoma, and primary central nervous system lymphoma. Table 2 provides an exemplary list of cancers which can be treated using the methods and formulations of the present invention, and the current standard of care used to treat these cancers as well as investigational treatments used to treat these cancers.

TABLE 2 Standard of Care and Investigational Type of Cancer Description of the Cancer Treatments Lung Cancer Lung cancers are grouped as Surgical removal of non-small cell bronchogenic non-small cell (NSCLC) or carcinoma continues to offer best possibility of a small cell (SCLC), but cure. within the former certain Radical radiotherapy is indicated for patients with patterns of disease do relate who are unfit for surgery, or have good to histological subtype. For performance status and disease that can be example, squamous cancers encompassed in a radical volume. The standard typically arise in proximal international dose is 60 Gy in 30 fractions over 6 segmental bronchi and grow weeks. The standard treatment volume in most of slowly, disseminating the world is the primary tumor and hilar and relatively late in their course. mediastinal lymph nodes, with a 1-2 cm margin. Adenocarcinomas are often Chermotherapy delivered synchronously with peripheral in origin and even radiotherapy is being investigated. small respectable lesions Cisplatin-based therapy significantly improves carry a risk of occult survival and quality of life. The most studied metastases. regimen is MIC (mitomycin C, isosfamide, and cisplatin) . . . Combination chemotherapy is now the standard treatment for limited and extensive SCLC. Patients with small cell lung cancer (SCLC) are usually treated by primary chemotherapy because of its chemo-responsiveness and frequent dissemination at time of diagnosis. SCLC is, however, also the most radio-responsive variety of bronchial carcinoma and radiotherapy has an important role in its management. In patients with a localized tumor, thoracic irradiation (TI) and prophylactic cranial irradiation (PCI) improve disease control at these sites and can lead to prolongation of survival. The following courses of radiotherapy are commonly used: TI-50 Gy in 2Gy daily fractions or biological equivalents; PCI-24 Gy in 8 fractions, 30 Gy in 10 fractions, or 36 Gy in 18 fractions. It is common practice to irradiate the mediastinum even in the absence of lymphadenopathy because of frequency of occult nodal metastases. A number of chemotherapeutic drugs have been found to have activity as single agents and a variety of combination regimens have been developed. CAV (cyclophosphamide, doxorubicin and vincristine) and EP (etoposide and cisplatin) have similar efficacy. Malignant pleural Aggressive tumor arising Without treatment, the average patient with MPM mesothelioma (MPM) from the serosal lining of the survives less than one year from the time of chest and abdomen with diagnosis. As a result of this poor prognosis survival rates of less than various therapeutic options have been explored, one year reported following including radiotherapy, chemotherapy, diagnosis. immunotherapy and surgery. Current experience has shown multimodality therapy to offer improved survival in selected patient groups. Thymic Tumors Tumors derived from the The contemporary standard of treatment for thymus (thymomas) thymoma is radical surgery whenever possible. comprise approximately 20% Total resection alone is adequate therapy for early of all mediastinal tumors and stage thymoma. Adjuvant therapy should be used are the most common tumor for local disease with demonstration or suspicion in the anderior mediastinum. of invasion. In local disease with or without Thymomas occur at any age residual tumor, radiotherapy is recommended in but are rare before the age of doses of 50-60 Gy given in 20-30 20 and peak between 40-60 fractions. Locally advanced, relapsing, or years. disseminated disease should be treated with Most thymomas are slow- combination chemotherapy including growing ‘low-grade’ corticosteroids. Cisplatin-based regimens are malignant tumors. It is recommended. believed that they derive from epithelial elements, but the tumors retain the capacity for production of T cells. Breast Cancer Breast cancer is the most Early breast cancer is defined as disease that can common solid cancer be completely extirpated by surgery. The occurring in women. It is management of this disease comprises: treatment estimated that 5-10% of of the breast and axilla; pathological staging to female breast cancer is due direct adjuvant therapy; adjuvant therapy- to inheritance of a mutated endocrine, chemotherapy, radiotherapy; and copy of either BRCA1 or follow-up. BRCA2. Other genes All patients require removal of the primary tumor contibute less frequently to with either wide local excision or mastectomy. familial breast cancer. Male Breast irradiation has been shown to reduce the breast cancer is rare (0.7% of risk of local recurrence after breast-conserving all male cancers) with a peak surgery. Typically, the whole breast is treated incidence 10 years later than with tangential fields to a dose of 50 Gy in 25 women. It may occur in fractions (or an equivalent dose-fractionation association with Klinefelter's regimen), with care taken to minimize the volume syndrome. of lung and heart irradiated. Ductal carcinoma in situ Primary chemotherapy or hormone therapy for (DCIS) operable breast cancer provides early systemic 90% of breast carcinomas treatment and allows assessment of the response arise in the ducts of the to treatment; by definition this is impossible with breast, beginning as atypical adjuvant therapy. Studies have compared pre- and proliferations of ductal post-operative chemotherapy (doxorubicin and epithelium that eventually cyclophosphamide). Pre-operative treatment does fill and plug the ducts with downstage the primary tumor and may facilitate neoplastic cells. As long as breast-conserving surgery where mastectomy the tumor remains within the would otherwise be required. confines of the ductal Locally advanced disease is defined by the basement membrane it is presence of infiltration of the skin or the chest classified as DCIS. Not all wall or fixed auxiliary nodes. The probability DCIS will inevitably of metastatic disease is high. progress, but the probability of development of invasive cancer is estimated at 30-50%. Lobular carcinoma in situ Local control of the tumor and the prevention of These pre-invasive lesions fungation are of major importance to the quality carry a risk not only of of life. A combination of primary systemic ipsilateral invasive lobular treatment and radiotherapy is commonly used. carcinoma but also of Many of these patients have indolent ER-positive contralateral breast cancer. disease that responds to endocrine therapy with Invasive ductal carcinoma tamoxifen, aromatase inhibitors, or progestins. In younger women with aggressive ‘inflammatory’ breast cancer, primary chemotherapy is preferred. This accounts for 75% of In patients with a good response to systemic breast cancers. The treatment surgery may be feasible. malignant cells are In management of metastatic breast cancer, associated with a fibrous treatment with tamoxifen, ovarian ablation. stroma that can be dense progestins, or aromatase inhibitors may provide (scirrhous carcinoma). The an response in patients with advanced disease, tumor invades through and in 50-60% of those with ER-positive tumors. breast tissue into the Disease that responds to endocrine therapy and lymphatics and vascular then progresses has a 25% response rate with spaces, to gain access to the second-line treatment; the response to a third regional nodes (auxiliary agent is 10-15%. and, less often, internal Advanced breast cancer is moderately mammary) and the systemic chemosensitive. Active agents include circulation. antracyclines, alkylating agents, and Ductal carcinoma of special antimetabolites. Combinations such as FAC (5- type fluorouracil, doxorubicin, cyclophosphamide) A number of pathological produce response rates of 40-60%, with a median variants are identified, time to progression of around 8 months. 20-50% namely medullary of women respond to second-line chemotherapy carcinoma, tubular with a taxane and studies are currently evaluating carcinoma, and mucinous the promising combination of anthracycline plus carcinoma. taxane as first-line chemotherapy. Low-dose Invasive lobular carcinoma radiotherapy provides palliation in these patients. Lobular carcinomas account Bisphosphonates are used for treatment of for 5-10% of breast cancers. malignant hypercalcemia and can produce healing of some osteolytic metastases. Colorectal cancer Colorectal cancer is the Surgery is the mainstay of curative therapy for fourth commonest cancer colorectal cancer. Curative resection requires the worldwide. Around two- excision of the primary tumor and its lymphatic thirds of a million people drainage with an enveloping margin of normal will present with the disease tissue. each year. It affects men and The aim of adjuvant chemotherapy is to eradicate women almost equally and micro-metastases and thereby prevent future tends to be more common in relapse. Current available chemotherapy does not ‘developed’ countries and is completely eradicate bulky, advanced metastatic particularly common in the bowel cancer. It does however eradicate mico- US, Europe and Australia. metastases in a proportion of patients. Colorectal cancers area The current ‘international standard’ adjuvant almost always chemotherapy regimen for colon carcinoma is 5- andenocarcinomas. The fluorouracil (5FU) given in combination with tumor often starts as a folinic acid, by bolus intravenous injection. polypoidal mass and then tends to infiltrate into and through the bowel wall. A number of new oral preparations involving pro- drugs of 5FU and/or inhibitors of 5FU catabolism are being evaluated. Other research approaches involve regional delivery of 5FU to the tissues most at risk of containing micro-metastases, via the peritoneal cavity or the hepatic portal vein. New cytotoxic agents are continually under investigation, the most promising of which are Irinotecan (a drug which works by interfering with the nuclear enzyme topoisomerase-I), and Oxaliplatin (which forms covalently bonded adducts with DNA). Understanding the complex pathways by which 5FU acts has allowed the development of biochemical modulation techniques. Leurovorin enhances 5FU toxicity by stabilizing the interaction of thymidylate synthase and active 5FU metabolites. The optimum schedule of 5FU ± leucovorin administration has yet to be elucidated. Intravenous bolus 5FU, usually given with leucovorin, is currently most commonly used. Raltitrexed is a potent inhibitor of thymidylate synthase. It can be used as an alternative to 5FU- based regimes for first-line treatment. It does not require coadministration of a biochemical modulator. Intra-hepatic 5FU, following surgical placement of a hepatic artery catheter, may be considered for patients with unresectable liver metastases. There currently is no standard second-line chemotherapy treatment regime for patients previously treated with 5FU-based chemotherapy. Radiotherapy in colonic cancer is limited to the palliative situation in most circumstances. The rectum is a suitable target for radiotherapy. Radiotherapy has been used in both the pre- operative and post-operative settings in this disease. In the pre-operative situation there are a group of patients who present with large fixed or tethered tumors that are non-resectable. The conversion rate to respectability is 35-75%. with a dose of 50-60 Gy given over a five-week period. This group is also offered combined chemo- irradiation Anal cancer Most anal tumors arise from The standard treatment for anal canal tumors was the epidermal elements of abdominoperineal resection, while anal margin the anal canal lining growths were viewed as equivalent to skin tumors (squamous cell-85% of anal elsewhere and treated by local excision. Over the tumors), though some arise past few years, radiotherapy and/or chemotherapy from the glandular mucosa have become increasingly popular and in many of the uppermost part of the cases the treatment of choice. anal canal or from the anal Non-surgical treatment (chemo-irradiation) for ducts and glands anal cancer has become increasingly popular. The (adenocarcinomas). drugs used are usually 5FU and mitomycin C. The Malignant melanoma of the radiotherapy consists of 30 Gy of external-beam anus is very rare. irradiation over a period of three weeks. Traditionally, the anal region Althought Adenocarcinoma is radiosensitive, it is is divided into the anal canal usually treated by radical surgery. and the anal margin or verge. Esophageal cancer Squamous cell carcinoma is Surgical resection is the treatment of choice for the most common early stage disease. Advanced disease is histological type, but chemosensitive Post-resection irradiation adenocarcinoma is improves the loco-regional control in patients increasing in incidence . . . with positive resection margins, but not if there is nodal involvement. The dose is limited to 50 Gy in 25 daily fractions in patients who have undergone a gastric pull-up or intestinal interposition procedure. Pre-operative (neo-adjuvant) chemotherapy can downstage the primary tumor and treat micro- metastases before the post-operative, stimulatory surge of growth factors. Drugs effective in esophageal cancer include: 5FU, cisplatin, mitomycin, paclitaxel, and methotrexate. The most commonly used combination is continuous infusion of 5FU and cisplatin. The majority of esophageal tumors are diagnosed at an advanced stage when resection is not possible. Combined chemo-irradiation therapy is more effective than radiotherapy alone in locally advanced esophageal cancer. Gastric cancer Globally, stomach cancer is The type of surgical resection used in gastric the second commonest cancer will depend on the site of the tumor; cancer. esophogastrectomy may be required for cancers of 90% of stomach tumors are the esophagus/stomach/jejunum and proximal adenocarcinomas, that are stomach; total gastrectomy for mid-stomach futher divided into tumors, and partial gastrectomy may be adequate ‘intestinal’ and ‘diffuse’ treatment for tumors in the distal stomach. A types. The remainder are futher consideration is the extent of mainly lymphomas and lymphandectomy undertaken. leiomyosarcomas. Intestinal Recent studies of post-operative adjuvant type gastric cancers are radiotherapy are encouraging. Encouraging results ulcerative and occur more have also been seen with the use of mitomycin C. often in the distal stomach tegafur, as well as ECF (epirubicin, cisplatin, than diffuse types, including protracted venous infusion of 5FU) as post- linitinis plastica, which operative adjuvant chemotherapy. occur throughout the stomach. Small intestine and More than 35 pathological Surgical resection is the most important therapy carcinoid tumors variants of small bowel for all small bowel tumors. Chemotherapy for tumors have been described. most malignant small bowel tumors is based Most common are around 5FU applied either alone or in adenocarcinomas that combination with leucovorin and/or α-interferon. constitute 40% of all Sarcomas are treated, as at other sites, with malignant small bowel doxorubicin-based regimens. Similarly, tumors. Carcinoid tumors lymphomas are commonly treated with regimens represent 30% of all small such as CHOP (cyclophosphamide, doxorubicin, bowel malignancies. Other vincristine and prednisone). forms of tumors are Most patients with low-grade carcinoid tumors lymphomas, sarcomas, as can be treated with α-interferon alone or in well as benign tumors such combination with somatostatin analogs. as leiomyomas, angiomas Cytokine therapy (α-interferon) can be used both and lipomas. for adenocarcinomas and carcinoids of the small bowel, either alone or in combination with 5FU. Somatostatin analogs are useful for ameliorating clinical symptoms related to carcinoid tumors and also demonstrate some anti-tumor effect. Cancer of the liver Primary liver cancer or Surgery offers the only hope of cure for HCC. hepatocellular carcinoma However, resection is not possible in many (HCC) is prevalent in areas patients. Liver transplantation is appropriate for where hepatitis B is endemic. some cirrhotic patients. Hepatitis C infection is For irresectionable tumors systemic chemotherapy becoming an increasing has been used. A variety of cytotoxic drugs cause. Tumors may also be including doxorubicin, mitozantrone, found incidentally at the time methotrexate and cisplatinum have been used as of post-mortem examination single agents or in combination with 5FU. in patients with cirrhosis. Surgical ligation of the hepatic artery and insertion of a hepatic artery catherter have been used to deprive the tumor of oxygenated blood and to provide a route for the direct administration of cytotoxic chemotherapy. Such techniques have been superceded by the use of chemo- embolization via radiologically placed catheters in the hepatic artery. This technique is less invasive and, using chemotherapy such as adriamycin combined with lipiodol uptake by the tumor, is demonstratable on CT scan. Repeat embolization is performed at 2-3 month intervals and tumor regression with associated regeneration of normal liver may render some tumors resectable. Cancer of the biliary Microscopically, tumors of Chonangiocarcinomas should be resected if there tract the biliary tract are are no distant metastases and no irreparable adenocarcinomas of the involvement of the hepatic artery and portal vein. papillary, nodular, or It is advisable to perform a full lymph-node sclerosing type. Papillary dissection. tumors develop more Although cholangiocarcinomas are not generally commonly in the gall bladder considered chemosensitive or radiosensitive, or in the distal bile duct; responses to chemotherapy with cisplatin and 5FU sclerosing and nodular and folinic acid have been observed. Newer agents tumors, in the proximal bile such as gemcitabine and irinotecan are under duct. Adenocarcinomas investigation. without specific features are For tumors of the gall bladder, incidental tumors the most common. diagnosed after a laparoscopic cholecystectomy Tumors of the bile duct can need no further action unless the gall bladder was develop within the bead of ruptured. Tumors of more advanced stages should the pancreas, in the be treated with radical surgery. Post-operative hepatoduodenal ligament, or chemotherapy with cisplatin has yet to be proven at the level of the hepatic to provide beneficial results. Radiotherapy is used hilum,. Hilar in cases of incomplete resection. cholangiocarcinomas (Klatskin's tumors) account for more than half in most series. Cholangiocarcinomas, especially of the sclerosing and nodular type, infiltrate along the walls of the ducts and the perineural tissue before obstructing the lumen. Metastases to the lymph nodes are seen in some patients undergoing surgery. Direct duodenal invasion and peritoneal carcinomatisis occur late. Tumors of the gall bladder infiltrate the muscular wall of the gall bladder and the neighboring liver tissue, and spreads to the regional lymph nodes and to the liver. Distant metastases occur late. Pancreatic cancer The majority of exocrine Resection is the only treatment that offers the tumors are ductal possibility of a cure at this time. There is no adenocarcinomas and 1-2% standard chemotherapy for pancreatic cancer. The are acinar; the remainder are nucleoside analogue, gemcitahine, may improve of diverse histology. Genetic survival compared to a simple 5FU regimen. abnormalities found in Adjuvant therapy using 5FU, doxorubicin, and pancreatic cancer include the mitomycin C may also increase survival. K-ras oncogene (90-100%) Patients with good performance status and and mutations in p53 (60%), localized resectable tumor may be considered for p16 (80%), and SMAD4 radiotherapy, with or without chemotherapy. 5FU (50%) tumor suppressor has been shown to increase median survival after genes. Spread is mainly to radiotherapy (35-40 Gy). With 3D-CT planning of retroperitoneal tissue, the external-beam radiotherapy it is possible to liver, and the peritoneum, deliver 50.4 Gy in 28 daily fractions to pancreatic with distant metastases to the tumors without exceeding tolerance for the lung, liver, and the bone. adjacent stomach, bowel, or kidneys. Both eternal-beam radiotherapy (EBRT) and intra- operative radiotherapy (IORT) have been used in the adjuvant settings. Thyroid cancers Classification of thyroid Management of differentiated thyroid cancer cancers is made on a begins with radical thyroidectomy. Radioiodine histological basis: therapy (40-80 mCi = 1500-3000 MBq) to ablate differentiated (papillary or the thyroid remnant follows the operation. follicular), anaplastic, External beam radiotherapy is delivered to the lymphoma, and medullary. neck where the tumor was locally invasive at Lymphomas are high grade operation (giving a dose of 5000 Gy in 5 weeks). immunoblastic non- If the patient presents with metastatic disease, or Hodgkin's tumors. at relapse after partial thyroidectomy, radical Medullary carcinoma of the thyroidectomy and ablation is still required. thyroid arises from the Following radical thyroidectomy and radioiodine parafollicular C cells (the ablation of the stump, the patient has at least two cell of origin of calcitonin). whole body radioiodine whole body profile scans For recurrent disease, serum in the next 1½ years. calcitonin serves as a good The treatment of neck nodal disease is surgical marker, resection followed by radioiodine therapy where appropriate. Metastatic disease further afield is treated by serial doses of radioiodine (150 mCi = 5500 MBq). Iodine therapy is continued at 4-6 monthly intervals until maximal remission. In patients who do not relapse, blood checks should be made to ensure thyroid stimulating hormone (TSH) suppression and minimal serum thyroglobulin readings (<2 μg/L). For Anaplastic carcinoma, radiotherapy to the neck is the standard, with palliative chemotherapy as a systemic alternative. These tumors are rarely a radical surgical proposition and do not take up iodine. Lymphomasare treated with a combination of combination chemotherapy and wide field radiotherapy to the neck. For medullary carcinoma, surgical clearance of apparently localized disease to the neck is the first therapeutic step. For recurrent disease . . . occasional avidity of uptake to metaiodobenzylguanadine (MIBG) makes radioiodinated MIBG therapy a possibly useful therapeutic modality. Adrenal cancer The adrenal gland is The mainstay of treatment is surgical resection. composed of a cortex and a For phaeochromocytomas with residual or medulla and the tumors that unresectable disease, anti-hypertensive medication arise in these two regions are may be required to control the blood pressure. If aetiologically and the tumor takes up the radionuclide MIBG, a functionally different, therapeutic dose of up to 10,000 MBq of ¹³¹I- reflecting their cells of MIBG may be administered. Although these origin. Adrenocortical tumors were traditionally considered to be chemo- carcinomas are usually resistant, a combination of dicarbazine (DTIC). adenocarcinomas and vincristine, and cyclophosphamide shows activity. malignancy is confirmed by Other regimens which include cisplatin and the presence of metastatic etoposide have shown promise. spread. These tumors extend For unresectable or metastatic adrenocortical locally to nodes and the liver tumors, Mitotane (opDDD) is the first-line but have a high frequency of treatment. Metyrapone, antiglutethamide, and distant spread. Adreno- ketoconazole are second-line medical therapies. medullary tumors The most active chemotherapy drugs appear to be (phaeochromocytomas) are cisplatin and etoposide. The role of external rare, and can be difficult to radiotherapy is often for the treatment of diagnose. symptomatic metastases, usually in bone. Neuroblastoma Neuroblastoma is the Surguery is usual for tumors in the thorax. In the commonest extracranial past, later stage tumors were treated with intensive solid tumor in childhood. chemotherapy. It is now recommended that, if Tumors arise in sympathetic possible, surgical clearance be attempted, but if nervous tissue. Morphology this is not feasible then non-intensive ranges from a very chemotherapy, such as Vincristine. Cisplatin, undifferentiated, small, Etoposide and Cyclophosphamide (OPEC) or round cell tumor that may be Vincristine, Carboplatin, Etoposide and difficult to distinguish from Cyclophosphamide (OJEC), followed by delayed rhabdomyosarcoma to a surgery, be used. highly differentiated MIBG posivity, post-operatively, indicates likely ganglioneuroblastoma. residual primary tumor, and local radiotherapy is indicated. An alternative is the use of I¹³¹ MIBG- targeted radiotherapy. High-dose melphalan with peripheral blood stem rescue is also used. Alternative high-dose intensity strategies, such as administering treatment every 10 days or escalating the dose of cyclophosphamide are also under investigation. For late stages of disease occurring in infants less than 1 year of age, intervention with chemotherapy or radiotherapy may be appropriate. Low-dose irradiation to the liver or low-dose chemotherapy using vincristine or combinations of cyclophosphamide, doxorubicin, or carboplantin/etoposide are indicated. Renal cancer Adenocarcinomas make up Renal transitional cell carcinomas are managed the vast majority of renal similarly to transition cell carcinomas of the cancers. They were bladder. previously known as Resection of the tumor is the standard. In patients ‘hypernephroma’ or ‘Grawitz with limited metastatic disease, nephrectomy may tumors’. Transitional cell be indicated. Adjuvant therapies consisting of carcinomas can arise within cytotoxic chemotherapies, endocrine therapy. the urothelium of the renal radiotherapy, and interferon have been tested in pelvis and represent the this disease. Vinca alkaloids are the most majority of the remaining commonly used chemotherapeutics. With respect tumors. Transitional cell to endocrine therapy, progestins are widely used, carcinomas arise in the renal although progestagens can also be useful. collecting system. Renal Biological therapy has been extensively tested in tumors may invade locally or renal cancer. Interleukin-2 (IL-2) is the most may metastasize to the lungs, widely tested biological agent, alone or in lymph nodes, bone and combination with lymphokine-activated killer brain. cells (LAK). Less toxic subcutaneous IL-2 regimens are also effective and can be combined with interferon-α (IFN) and/or cytotoxics. Wilms' tumor Wilms' tumor (WT) is an Surgical extirpation is the fundamental treatment embryonal neoplasm arising for Wilms' tumor. Pre-operative chemotherapy in the kidneyClassical may be beneficial. The use of chemotherapy and ‘triphasic’ WT has stromal, radiotherapy as adjuvants to surgery is an essential blastemal, and epithelial part of WT treatment. Chemotherapeutic agents elements. The bone- which have been employed include actinomycin D metastasizing renal tumor (AMD) plus vincristine (VCR). AMD plus VCR (clear cell sarcoma) and plus doxorubicin, and AMD plus VCR plus malignant rhabdoid tumor doxorubicin plus cyclophosphamide. are pathologically and genetically distinct entities. Cancer of the bladder The majority of urothelial The usual surgical procedure is and ureter tumors are transitional cell cystoprostatectomy in male patients or anterior carcinomas. Pure squamous bladder exenteration in female patients, with carcinomas and dissection of local lymph nodes. Radical adenocarcinomas represent radiotherapy based on CT scan has let to about 5% of tumors, increasing precision and more accurate dosimetry. although metaplasia can Usually the entire bladder is treated to encompass occur in a primary the risk of sublinical disease at other sites in the transitional tumor. There is a urothelium. The technique uses either three or link between four fields and the common fractionation andenocarcinoma of the regimens include treatment to a dose of 64 Gy in bladder and presentation of 32 fractions over 6½ weeks or 55 Gy in 20 the tumor in the bladder fractions over 4 weeks. dome, often associated with Chemotherapy has been investigated as an persisting urachal remnant. adjuvant therapy in localized disease either prior Squamous cancers of the to, or following, local treatment with surgery or bladder are associated with radiotherapy. Combination chemotherapy has an chronic bladder infection by established role in the palliation of patients with Schistosoma haematobium. incurable bladder cancer. Typical combinations include M-VAC (methotrexate, vinblastine, adriamycin and cisplatin) and CMV (cisplatin, methotrexate and vinblastine). New drugs under investigation for the management of bladder cancer include taxanes, gemcitabine and ifosphamide. Prostate cancer Pathogenesis of cancer of the Measurement of PSA should be done in all prostate gland is clearly patients with outflow symptoms, and is routinely androgen-dependent. Since used as a screening tool in the US. PSA levels >4 mg/ml the development of assays to are considered to be suspicious; transrectal measure prostate-specific ultrasound and needle biopsy are called for in antigen (PSA) to diagnose these patients. PSA levels >50 ng/ml may be prostatic disease, the indicative of distant metastases. condition has been For treatment of disease confined to the prostate, increasingly diagnosed at an radical local therapy (prostatectomy or earlier stage. More patients radiotherapy) should be considered. Good results are presenting with early have been seen with neo-adjuvant anti-androgen stage disease and suitable therapy when followed by radiotherapy in locally treatment strategies are extensive disease. required to cure those that Once the tumor has spread beyond the local can be cured and palliate lymph nodes, useful palliation of the disease can optimally those that cannot. be achieved by hormonal therapy. Treatments used to produce cessation of androgen-driven growth of the cancer include surgical castration. estrogens, steroidal anti-androgens such as cyproterone acetate, non-steroidal anti-androgens (flutamide, bicalutamide), and medical castration with LHRH agonists. The combination of medical castration and anti-androgen therapy has been used. The chemotherapeutic anthracyclines and the related mitoxantrone have been reported to be useful. Radiation therapy offers useful palliation of advanced disease both in bone and soft tissue. In addition, radioactive strontium given by IV injection (150 MBq) has proved effective in relieving bone pain and delaying the progression of symptomatic bone disease. Testicular cancer Testicular cancer is the The management of seminoma and non- commonest cancer in young seminomatous germ cell tumors depends on the men. The majority of stage of the disease. Initial management of testicular cancers are germ testicular germ cell tumors generally includes cell tumors which arise in inguinal orchidectomy, although in cases with the germinal epithelium. widespread metastases immediate chemotherapy Both seminomas and non- may be appropriate. Carcinoma in situ will seminomatous germ cell progress to invasive cancer, either seminoma or tumors are thought to arise non-seminomatous germ cell tumors. Low-dose from pre-existing carcinomas ratiotherapy to the testis (20 cGy in 10 fractions in situ. Non-germ cell over 2 weeks) is useful in early stage patients. testicular tumors have been Standard doses of radiotherapy (30 Gy in 15 observed as well . . . fractions over 3 weeks) and chemotherapy are Non-seminomatous germ cell appropriate for later stage patients. tumors produce markers in the form of the human chorioric gonadatrophin (HCG) and/or alpha feta protein (AFP) in a majority of cases. Seminomas have no reliable tumor marker with which to monitor disease, although HCG may be raised in about 25% of cases. The lactate dehydrogenase (LDH) may be raised in both tumors as well. Ovarian cancer Ovarian cancer is the fifth Treatment consists of surgery, followed for most commonest cancer in patients with platinum-based chemotherapy women. Over 80% of regimens. For patients who cannot be optimally ovarian malignancies are debulked at initial laparotomy, interval debulking epithelial, the rest comprise surgery after three cycles of chemotherapy confers germ cell and stromal a significant survival benefit. The standard tumors. Epithelial cancers chemotherapy regimen currently consists of are classified by their cell cisplatin-paclitaxel, although carboplatin- type (serous, mucinous, paclitaxel has produced promising results. A endometroid. Brenner, number of new agents, including topotecan. mixed) and by their grade. liposomal doxorubicin, etoposide. gemcitabine. 80% of women with and altretamine also have shown response in this advanced ovarian cancer setting. A number of new approaches are also have elevated serum CA125 under consideration, including intra-peritoneal and this marker is valuable chemotherapy. high-dose systemic chemotherapy. in monitoring response to biological response modifiers, metalloproteinase therapy and for detection of inhibitors, and anti-angiogenic agents. early relapse. Cancer of the uterine By far the commonest cancer The usual indication for radiotherapy in corpus of the uterine corpus is endometrial cancer is as adjuvant therapy carcinoma of the following hysterectomy but less commonly it may endometrium; less common be used as a primary treatment, as a follow-up are the uterine sarcomas. Of treatment when residual tumor remains following the latter, some have a surgery, for treatment of inoperable tumors, or glandular element, the so- for treatment in cases of recurrence. Adjuvant called Mixed Mesodermal radiotherapy is generally delivered with external- Mullerian Tumors (MMMT) beam irradiation of a planned volume (usually or carcinosarcomas, and four fields) to around 50 Gy over four weeks. some are fibrosarcomas. Chemotherapeutic combinations such as cisplatin The epidemiology of uterine and doxorubicin have been shown to have some sarcomas is less well-defined activity in endometrial cancer. Progestagens have than endometrial carcinoma, been widely used in the past but should not be although cases of mixed used as long-term adjuvant therapy. Mullerian tumor have been Successful treatment of MMTs depends on reported following tamoxifen surgery for localized disease. Residual disease or therapy. The mixed tumors with nodal or distant metastases are Mullerian tumors are divided usually incurable. Hysterectomy and bilateral into homologous and salpingo-oophorectomy should be performed. heterologous. Homologous together with pelvic and para-aortic MMTs are composed of lymphandectomy. Residual disease can be treated tissues native to the uterus, with radiation. Adjuvant radiation may be of use. whereas heterologous MMTs Chemotherapy (e.g. doxorubicin and ifosfamide) involve tissue from outside is often used in cases of metastatic disease. the uterus. Fibrosarcomas may arise de novo or rarely are found in a fibroid uterus. Cancer of the cervix In developing nations, When the disease is confined to the cervix, patient cervical cancer is the most management depends on the cytology and/or common female cancer. histology specimens, Histology can reveal a The type of surgical treatment to be used will spectrum of changes in the depend upon the stage of the disease. epithelium of the cervix, Radiotherapy is typically used; a standard therapy including slight dysplastic consists of external-beam irradiation (40-45 Gy to changes in the cell the pelvis for 4 weeks) followed by intra-cavity architecture, viral brachytherapy (ICT) in the uterus/upper vagina or cytoplasmic changes, intra- to the central pelvic structures. Although epithelial neoplasia, micro- chemotherapy does not have an established role in invasive carcinoma, and the treatment of cervical cancer at this time, frank invasive carcinoma. patients with recurrent pelvic or systemic metastatic disease may benefit from it. The principal active agents are cisplatin, mitomycin C, ifosfamide, methotrexate, 5-fluorouracil, and bleomycin. Modern management of advanced disease regularly involves the use of concurrent or sequential chemotherapy and radiotherapy. Vaginal and vulvar Most vaginal malignancies Radical radiotherapy with a combination of pelvic cancer are metastatic, from primary external-beam and utero-vaginal intra-cavitary sites in the cervix, vulva, brachytherapy is the treatment of choice for endometrium, or trophoblast vaginal cancer. Lower vaginal involvement should (choriocarcinoma). The most prompt consideration of either additional groin common histological types node dissection or irradiation. of primary cancer are Primary treatment of invasive vulvar cancer squamous and consists of surgical excision with clear margins adenocarcinoma. and removal of groin nodes. Chemo-irradiation In primary invasive vulvar (typically 5FU and mitomycin C combined with cancer, the majority are radiotherapy) used in cases of advanced disease squamous carcinoma; other shows encouraging results. types include basal carcinoma and malignant melanoma. Trophoblastic tumors Gestational trophoblastic Treatment of hydatiform moles may include disease (GTD) includes a gentle suction curettage. Hysterectomy or spectrum of disorders cesarean section increases the risks of ranging from the pre- chemotherapy being required to eradicate malignant complete persistent trophoblastic disease. The stage of the hydatidiform mole (CHM) disease is used to determine what chemotherapy and partial hydatidiform regimen is appropriate. Methotrexate is commonly mole (PHM), to the used in later stage patients. Combination malignant invasive mole, chemotherapy comprising etoposide. gestational choriocarcinoma, methotrexate, and actinomycin D (EMA) and the highly malignant alternating weekly with cyclophosphamide and placental-site trophoblastic cincristine (CO) may be used in very late stage tumor (PSTT). Both CHM patients. Treatment with methotrexate or and PHM can develop into EMA/CO regimens continues until the HCG has invasive moles. However, it been normal for six weeks. is thought that only CHM Choriocarcinoma Where it can be safely achieved. may progress to the highly excision biopsy of a metastasis should be used to malignant choriocarcinoma confirm the diagnosis. Patients are scored and and the rare PSTT. treated the same as for molar disease. Choriocarcinoma is a highly The behavior or PSTT is quite different from malignant form that other forms of GTD and it is relatively usually presents within one chemoresistant. The best management is year of pregnancy. One third hysterectomy when the disease is localized to the of patients present with uterus. When metastatic disease is present, metastases to the liver, brain patients can respond to multi-agent chemotherapy or lung. either alone or in combination with surgery. PSTT can develop following a term delivery, non-molar abortion, or CHM. PSTTs are slow-growing malignant tumors composed mainly of cytotrophoblast with very little syncytiotrophoblast, so producing little HCG. However, they often stain strongly for human placental lactogen (HPL) which helps distinguish this tumor from carcinomas, sarcomas, exaggerated placental-site reaction, and placental nodule. In most cases spread occurs by local infiltration with distant metastases occurring late via the lymphatics and blood. Cancer of the larynx Tumors arising from the The main treatment modalities are radiotherapy mucosa of the larynx make and surgery. Induction chemotherapy may select up the majority of tumors in patients with advanced carcinoma suitable for the larynx. full-course radiotherapy to save the larynx. The voice may be better spared by radiotherapy than surgery. Cancer of the oral Squamous cancers of the oral Surgery is the most common treatment for early cavity cavity are associated with tumors; primary radiotherapy and reserve surgery heavy consumption of both for later stage disease. Locally advanced disease is tobacco and alcohol. The best treated by a combination of surgery and other less common radiotherapy. Doses of 50-65 Gy are delivered to malignancies of the oral the tumor volume, depending on the extend of the cavity include salivary, residual tumor. At least part of this dose can be tumors (adenoid cystic, delivered by interstitial therapy. As with head and mucoepidermoid, and neck squamous cancers at other sites, adenocarcinoma), chemotherapy (cisplatin, 5FU, methotrexate, melanomas, plasmacytomas, bleomycin) is active in advanced disease. and sarcomas. Carcinoma of the NPC spreads into the NPC is generally both radio- and chemosensitive. nasopharynx parapharyngeal space Radiotherapy is the mainstay of treatment. The laterally. Any of the cranial role of surgery is restricted to staging and the nerves can be involved in the elective dissection of neck nodes. Radiotherapy tumor. Cervical lymph node planning is complicated in this disease due to its spread is common. Distant location in the body. Brachytherapy may be used spread to bone, the liver and to increase the dose to the primary site. Local or lung is common in advanced regional recurrence can be treated by a second stage disease. radical course of radiotherapy. There may be advantages to using chemotherapy prior to radiotherapy in this disease. Commonly used chemotherapy agents include 5FU, cisplatin and bleomycin. Combined radiation and chemotherapy regimes show promise. Cancer of the nasal The sinonasal region offers a Surgery alone or in combination with radiotherapy cavity and paranasal great histological diversity of is required in the majority of cases. Radiotherapy sinuses tumors, with squamous cell may be given before or after surgery where carcinoma the most common. appropriate. Megavoltage photons are optimally Due to the intimate used, in a dose of 60-66 Gy in 30-33 fractions relationship between the over 6-6.5 weeks. Concurrent chemo-irradiation nasal cavity and sinuses and therapy is under investigation. A number of the orbit and skull base, the chemotherapeutic agents (cisplatin, 5FU, tumors may spread early to methotrexate, bleomycin) have significant activity these areas. Additionally, in recurrent or metastatic disease. anterior spread into the soft tissues of the face, posterior involvement of the pterygoid region and nasopharynx, and inferior spread to the oral cavity are also commonly encountered. Distant lymphatic and hematogenous spread are rare in the early stages of disease. Basal cell carcinoma of Basal cell carcinomas occur Radiotherapy can be used as primary treatment, the external eye-skin, frequently on the face and following excision when the surgical margins are lids, lacrimal glands particularly around the eye. positive, or where a recurrence has occurred. They have a prediliction for Superficial X-rays (100-150 kV) are appropriate the lower lid margin and (e.g. 45 Gy in 10 daily fractions). adjacent inner canthus. It is unusual for the upper eyelid to be involved. Surgical excision is often appropriate. In more extensive lesions or where surgery is contraindicated, radiotherapy can be given. Non-Hodgkin's Lymphoma may involve the Low-grade lymphoma is treated with local Lymphoma of the eye upper and lower radiotherapy; high-grade lymphoma with localized and orbit lids/conjunctiva, major disease is treated with chemotherapy followed by lacrimal gland, or orbit. local radiotherapy. Other stages are treated with chemotherapy. Squamous and Squamous carcinoma arising from the skin, lids, adenocarcinoma of the or very rarely the conjunctiva can be treated with eye and orbit radiotherapy. Sebaceous and lacrimal gland tumors should be treated primarily with surgery. Melanoma of the intra- Melanoma can affect the Treatment may be observation, radioactive eye ocular region uveal tract; its most frequent plaque (ruthenium or iodine), local resection. location is the choroids. charged particles (proton beam), or enucleation. Local resection and proton-beam irradiation are used for larger tumors. Retinoblastoma This is a rare intra-ocular Photocoagulation can be used to treat small tumor arising in young tumors not adjacent to the macula or optic disk. children, usually in the first Small to moderate tumors can be treated with two years of life. radioactive plaques. External radiotherapy is used to treat large or multiple tumors. It may be necessary to radiate the entire eye (40 Gy in 20 fractions over 4 weeks). These tumors are often chemosensitive, and chemotherapy can be particularly useful as a neo-adjuvant or when the tumor has a poor prognosis. Useful chemotherapeutic agents include platinum, etoposide, vincristine, doxorubicin and cyclophosphamide. Optic nerve tumors Optic nerve tumors are rare and are usually treated by surgery. When excision is not possible, high- dose radiotherapy can be given, usually using paired wedge fields and giving doses on the order of 55 Gy conventionally fractionated. Rhabdomysarcoma of This rare tumor is most the intra-ocular region frequently located in the orbit. Metastatic disease of Metastatic disease involving Treatment with radiotherapy should usually be the intra-ocular region the eye is usually associated with a lateral field to the orbit giving 20 Gy in five with choroidal metastases. fractions over a week. The field may be angled The commonest tumors five degrees posteriorly to avoid the contralateral implicated are lung and lens. breast. Widespread bone metastases may affect the eye. Systemic treatment is often appropriate, although local radiotherapy may be helpful. Salivary gland tumors The most common tumor of In treatment of malignant salivary gland tumors, the parotid gland is the adjuvant radiotherapy is most commonly pleomorphic adenomal, also delivered post-operatively, but also as a split- known as the mixed parotid course, giving two-thirds of the treatment before tumor. Ocasionally this and one-third of the treatment after the operation. benign tumor can undergo Post-operative radiotherapy reduces the incidence malignant transformation. of local recurrence. Orthodox radiotherapy Most acinic cell and techniques use 6-10 MV photons, often with a mucoepidermoid tumors are wedged pair of fields, to give a dose of 55-65 Gy low grade, although some over 6-7 weeks. More aggressive tumors including may be high grade and more mucopidermoid, adenoid cystic, and aggressive with local undifferentiated carcinomas appear initially to invasion and a tendency to respond well to chemotherapeutic agents. The metastasize to lymph nodes most commonly used agents are cisplatin and and through the bloodstream. 5FU. Wide removal is recommended for pleomorphic adenomas and acinic cell and mucoepidermoid tumors, and will cure the majority of tumors. Carcinomas exhibit more aggressive behavior. Primary brain tumors Primary brain tumor Surgery and radiotherapy remain the mainstays of pathology is extremely treatment for these tumors and most advances varied reflecting diverse involve applying these modalities more effectively histogenesis. Gliomas are the to more precisely delineated tumors. Post- most common tumors. operative radiotherapy is normally given. The area Primary brain tumors rarely irradiated us usually limited to tumor-bearing metastasize outside the CNS brain and doses of 30-60 Gy are given over 2-6 but are highly infiltrative, weeks. Chemotherapy is usually reserved for with a tendency to spread relapse. The nitroureas including carmustine along white matter tracks to (BCNU) and lomustine (CCNU) are the most more distant regions of the common agents used. Procarbazine and the brain. Spread through platinum compounds and temozolomide may also cerebrospinal fluid (CSF) to have some value. Following surgical clearance the remote areas of the neuraxis application into the resection cavity of sustained- is a feature of germ cell release chemotherapy (BCNU-Gliadel) has shown tumors, medulloblastoma, some benefit. Third generation radiation and other primitive sensitizers such as the hypoxic cell cytotoxin neuroectodermal tumors. tirapazamine have shown promise. Angiogenesis inhibitors may be of use, and the drug thalidomide has shown some activity. Modification of the local environment with O-6-alkylguanine DNA alkyltransferase inhibitors or blood-brain barrier modifiers may improve results with chemotherapeutic agents. Brain metastases Metastases to the brain from Initial management requires control of the an extracranial primary site presenting symptoms with medication. is common. Dexamethasone is indicated in the majority of patients. A starting dose of 8-16 mg per daily is common and improvement can often be maintained with doses of 2-4 mg. For patients whose condition is improved following treatment with dexamethasone, radiotherapy can be offered. Typically, the whole brain is irradiated, with a dose of 20 Gy in five fractions being effective. When a solitary metastasis is present, tumor resection, if possible, is the treatment of choice. Post-operatively, whole-brain radiotherapy is given (20 Gy in 5 fractions or 30 Gy in 10 fractions) with or without a local boost. Chemotherapy can be useful in patients with brain metastases from chemo-sensitive primary tumors. It should be used as a first-line therapy (or following resection) in germ cell tumors or as an alternative to radiotherapy in small cell lung cancer or lymphoma. It can also be used as second-line treatment in less chemo-sensitive tumors such as breast cancer. Primary cutaneous Primary cutaneous malignant Treatment is complete excision of the lesion. Late malignant melanoma melanoma arises from stage melanoma may require dissection of melanocytes in the basal skin regional lymph nodes. Adjuvant alpha interferon layer may be of use. Chemotherapeutic regimens include DTIC and/or vindesine; the addition of tamoxifen may be of use. Interleukin 2 combined with with melanoma-directe vaccines are being investigated. Radiotherapy is generally reserved for palliation in metastasized cancer. Non-melanoma skin Commonest cancer in Standard treatment of basal cell carcinomas is cancers Western populations. surgical excision. Metastases are rare and are Basal cell carcinomas arise usually curable by surgical excision or on sun-exposed areas. radiotherapy. Other treatment strategies include Variant lesions include cryosurgery and topical 5FU. nodular, ulcerative, Treatment of squamous cell carcinoma is either pigmented, superficial, surgery or radiotherapy. Chemotherapy has been cystic, morphoeic, and used for disseminated disease (cisplatin, multicentric. methotrexate, 5FU, bleomycin). Squamous cell carcinoma Treatment of Merkel cell carcinoma is surgical. also arises on sun-exposed Palliative radiotherapy is useful in metastatic sites but is faster growing. disease. May metastasize to regional nodes Merkel cell carcinoma is a rare but highly malignant neuroendocrine tumor, commonly spreads to adjacent skin and regional nodes. Apocrine and eccrine gland cancers are rare and usually only locally invasive. Other uncommon skin malignancies include cutaneous angiosarcoma, Kaposi's sarcoma (HIV- associated or endemic), and other soft tissue malignancies. Acute lymphoblastic ALL is the commonest Treatment of ALL includes: leukemia (ALL) cancer in children. Chemotherapy: induction of remission is routinely achieved by combining vincristine, prednisolone, and l-asparginase. Additionaly anthracycline is used in adults. Consolidation is a crucial phase following remission. Exposure to new drugs is a key strategy (cyclophosphamide, thioguanine, cytosine arabinoside). Clearance of the central nervous system (CNS) as a sanctuary site is also key. CNS irradiation or MTX intra-thecally or high-dose IV chemotherapy are used. Maintenance of patients in remission is achieved using a cyclic schedule of methotrexate. 6 thioguanine, vincristine and prednisolone. Treatment of high-risk disease involves intensification in consolidation with cyclophosphamide or methotrexate in higher doses along with stem cell transplantation in first remission. Treatment following long remission consists of further chemotherapy or stem cell transplant. Acute myeloid Antracycline and cytosine arabinose given over 7-10 leukemia (AML) days is the backbone of treatment. Addition of a third drug (thioguanine or etoposide) is widely used. Giving higher ara-C doses in induction may be of benefit. Following induction, three or four further intensive courses incorporating other drugs (e.g. amasacrine, etoposide, idarubicin, mitoxantrone, and araC at higher doses) are usually given. Maintenance therapy no longer standard but may be useful, along with stem cell transplantation. Acute promyelocytic All-transretinoic acid (ATRA) used alone can leukemia induce remission. Additional chemotherapy, given alone or subsequent to ATRA is essential. Autologous transplantation or allogenic BMT widely used to consolidate first remissions. Arsenic compounds may be of use, as may refined stem cell transplantation and immunologically based approaches. Chronic lymphoid Chronic lymphoid leukemias Treatment of B-cell chronic lymphocytic leukemia leukemias are a heterogenous group of may not prolong survival of patients with conditions associated with lymphocytosis or uncomplicated accumulation of lymphoid lymphandenopathy. Systemic therapy is indicated cells in the peripheral blood for advanced disease or in cases with diffuse that may infiltrate into the infiltration or low lymphocye doubling time. bone marrow. Chlorambucil is first-line therapy. Single-agent B-cell chronic lymphocytic prednisolone (1 mg/kg/day) is useful in advanced leukemia is the common disease. Combination chemotherapy using COP or leukemia of late middle-age. CHOP has been evaluated . . . Purines are considered the best second-line therapy. Single- agent fludarabine standard. Chlorambucil also used at a dose of 25 mg/m² IV for 5 days on a 4-6 week cycle for up to 6 cycles. Radiotherapy is effective local treatment for lymph nodes. Splenectomy is effective for massive splenomegaly, anemia or thrombocytopenia and for conditions refactory to prednisolone and cytotoxic therapy. Hodgkin's disease Standard therapy for early stage Hodgkin's disease comprises nodal irradiation. Chemotherapy combined with limited (involved field) radiotherapy has been investigated. Chemotherapy regimens include VBM (vinblastine, bleomycin, methotrexate) and ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine). In cases with good prognosis involved field radiotherapy has been used alone successfully. For Advanced stage Hodgkin's disease, MOPP (mustine, vincristine, procarbazine, prednisolone) and its variants were standard until recently. Doxorubicin-based chemotherapy (particularly ABVD) is now considered standard. Newly introduced brief-duration regimens include: Stanford V (mustine, doxorubicin, vinblastine, prednisolone, vincristine, bleomycin, etoposide): BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisolone); and may be combined with limited field radiotherapy to sites of bulk disease. For salvage therapy in Hodgkin's disease, relapse after radiotherapy frequently responds to chemotherapy. Relapse after first line chemotherapy frequently responds to second line chemotherapy. High-dose chemotherapy and autologous stem cell transplantation becoming standard. Other promising therapies for Hodgkin's disease include high-dose chemotherapy and antibodies against CD30 antigen on R-S cell. Non-Hodgkin's Non-Hodgkin's For low grade NHL, treatment is reserved until lymphomas(NHL) lymphomas(NHL) are a active symptoms present. Local radiotherapy is group of malignant diseases applied to bulky sites. Single-agent chemotherapy arising from cells of the (chlorambucil), as well as combination therapy immune system. (CHOP) are standard. New treatments include High grade NHL is purine analogs (fludarabine, 2-CDA), autologous considered to have a strong tranplant, alpha interferon, palliation with anti- tendency to involve the CNS CD20 antibody (rituximab), antisense therapy to and is comprised of Burkitt's suppress Bcl-2 protein. lymphoma, lymphoblastic Burkitt's lymphoma is treated with intensive lymphoma, and diffuse large chemotherapy with methotrexate, B-cell NHL. Diffuse large B- cyclophosphamide, ifosamide, and with cell NHL is the commonest intrathecal therapy. high-grade NHL. Lymphoblastic lymphoma treatment includes emergency management of mediastinal obstruction and prevention of tumor lysis syndrome. Intensive combination chemotherapy schedules similar to ALL including CNS-directed therapy have been used. Allogenic and autologous progenitor cell transplantation may improve survival. Radiotherapy can cure early stages of diffuse large B-cell NHL. CHOP chemotherapy with radiotherapy to bulk disease is standard. Relapsed patients may respond to salvage chemotherapy and may benefit from autologous progenitor cell transplantation. Myeloma Myeloma (multiple Chemotherapy (oral mephalan, 4-day pulses every myeloma, myelomatosis) is 4 weeks for 3 months) is usually used for due to unregulated palliation. More intensive chemotherapy (VAD, proliferation of monoclonal vincristine and adriamycin by IV infusion an oral plasma cells in bone marrow. dexamethasone) may produce response. Combination chemotherapy (e.g. doxorubicin, BCNU, cyclophosamide, melphalan) may produce response as well. High-dose (marrow ablative) melphalan with autologous stem cell transpant can be considered in younger patients. Allogenic transplantation has been reported to improve survival. Oral clodronate may reduce the bone fracture rate when dosed continuously, as may pamidronate. Interferon-α may be used as maintenance therapy. Erythropoietin may be used to reduce transfusion requirements Osteosarcoma Osteosarcoma is the Surgical resection and use of chemotherapy in the commonest primary bone adjuvant (post-operative) or neo-adjuvant (pre- tumor and post-operative) setting has become standard. The most active chemotherapeutics include doxorubicin, cisplatin, ifosamide, and high-dose methotrexate. Osteosarcoma is relatively radio- resistant: radiotherapy rarely used as primary treatment, limited to palliative treatment or in metastases, when combined chemo-irradiation therapy is useful. Ewing's sarcoma Chemotherapeutic agents with substantial activity in Ewing's sarcoma include vincristine, doxorubicin, actinomycin D, etoposide, cyclophosphamide, and ifosfamide. Surgery and/or radiotherapy are used to treat the primary tumor. Lung metastases should be treated with conventional chemotherapy with whole-lung irradiation to any residual disease. Bone metasases may benefit from megatherapy after conventional induction treatment. Melphalan, busulphan, TBI, or a combination may be used as a conditioning regimen Primary malignant Primary malignant spindle Treatment is surgical removal. Chemotherapy is spindle cell sarcoma of cell sarcoma of bone being explored and may be of benefit. bone includes liposarcoma, angiosarcoma, leiomyosarcoma, and hemangiopericytoma. Osteoclastoma Osteoclastoma is usually Treated by curettage and bone packing or bone benign. resection and insertion of an endoprosthesis. Radiotherapy risks malignant transformation. Response to chemotherapy has been reported. Chondrosarcoma For low grade chondrosarcoma tumors, treatment is surgical resection with radiotherapy. For high grade tumors, treatment is combined surgery, chemotherapy and radiotherapy. Chordoma Surgery is treatment of choice. Radiotherapy (55-60 Gy) used after incomplete resection or as palliation. Particle therapy with protons has shown promise. Solitary plamacytoma Treatment is surgical resection or radiotherapy (45-50 Gy). Primary bone Localized high-grade treated with initial lymphoma chemotherapy (CHOP) followed by either radiotherapy or surgical excision with endoprosthesis. Multifocal or low-grade disease treated with chlorambucil chemotherapy and radiotherapy. Rhabdomyosarcoma Rhabdomyosarcoma (RMS) Treatment usually begins with combination (RMS) of the soft of the soft tissue is chemotherapy followed by local treatment tissue composed of embryonal (surgical resection with radiotherapy if excision is RMS and alveolar RMS. incomplete; radiotherapy alone if unresectable). Embryonal RMS may be treated with vincristine plus actinomycin D; may intensify treatment with ifosfamide, doxorubicin, other drugs. Additional drug such as etoposide and carboplatin and high- dose alkylating agent therapy may be of use. Highly sensitive to radiotherapy; common doses with chemotherapy are 40-50 Gy. Soft tissue Ewing's Much of management of RMS applies to sarcoma and primitive management of the Ewing's family of tumors. Pre- neuroectodermal tumor and post-operative combination chemotherapy is (PNET) crucial (doxorubicin, actinomycin D, ifosfamide, vincristine). Surgery is the preferred local treatment but radiotherapy is required after incomplete resection or for unresectable tumors. Adult soft tissue Radical surgery is standard for the primary soft sarcomas tissue sarcomas (STS). Radiotherapy may reduce local recurrence. Metastases may be surgically removed from the lungs. Chemotherapy for locally recurrent or metastatic disease is largely palliative. Ifosfamide and doxorubicin are the most active chemotherapeutic agents. Combination chemotherapy may be of use. Synovial sarcoma is chemosensitive. Adjuvant chemotherapy is not standard but may be useful. Cancer of unknown Cancer of unknown primary Effective palliation with chemotherapy is primary site site is categorized in four indicated if the tumor is chemo-responsive. broad groups: Combination chemotherapy has been investigated. adenocarcinoma, poorly Hormone therapy is valuable in breast, prostate, differentiated carcinoma, and endometrial cancer. Thyroidectomy and undifferentiated malignancy, radioactive iodine should be used in thyroid and squamous carcinoma. cancer. Radiotherapy can be palliative in bone metastases, brain metastases and for lymph node masses. Paraneoplastic Paraneoplastic syndromes syndromes are pathological conditions caused by a cancer but not due to direct local infiltration or metastatic spread. Cancers commonly associated with paraneoplastic syndromes include: lung (SCLC and NSCLC), pancreatic, lymphoma (NHL and HD), breast, prostate, and ovary. Endocrine Endocrine paraneoplastic Endocrine paraneoplastic syndrome is treated paraneoplastic syndrome is a syndrome of with fluid restriction and democycline (150-300 mg syndrome inappropriate anti-diuretic 8 hourly). hormone (arginine- Specific antibody treatments are used to treat vasopressin). Other related Cushing's syndrome. Standard treatment is to paraneoplastic syndromes decrease cortisol secretion surgicaly or medically include Cushing's syndrome, (metyrapone, ocreotide, ketoconazole). hypercalcemia, Hypercalcemia is treated with saline hydration hypocalcemia, and and IV pamidronate (60-120 mg). hypoglycemia. Hypocalcemia is treated with calcium infusions. Cushing's syndrome Hypoglycemia is treated with glucose infusions involves inappropriate and tumor debulking. overproduction of adenocorticotrophic hormone precursors. Hypercalcemia is due to tumor production of parathyroid hormone-related protein. Hypocalcemia is associated with bone tumors and calcitonin-secreting medullary carcinomas of the thyroid. In hypoglycemia, the most likely cause is tumor production of the precursor to insulin-like growth factor II. Neurological Neurological paraneoplastic Peripheral neuropathy is treated with paraneoplastic syndromes include corticosteroids along with treatment for the syndrome peripheral neuropathy, underlying cancer. encephalomyelopathy, Encephalomyelopathy is treated with anti-tumor paraneoplastic cerebellar therapy. degeneration, cancer- Paraneoplastic cerebellar degeneration is associated retinopathy, responsive to anti-tumor treatments, steroids, and Lambert-Easton myasthenic plasmapherisis. syndrome, and Cancer-associated retinopathy is treated with dermatomyositis/ corticosteroids. polymyositis. Lambert-Easton myasthenic syndrome is treated Peripheral neuropathy is with standard cancer treatment, corticosteroids, caused by axonal and plasma exchange. degeneration or Dermatomyositis/polymyositis is treated by demyelination. searching for and treating the tumor along with corticosteroids, and/or azathioprine. Hematological Hematological Erythrocytosis is treated with phlebotomy. paraneoplastic paraneoplastic syndromes Hemolytic anemia is treated by treating the tumor; syndromes include red cell disorders replacing coagulation factors, and supplying IV (erythrocytosis, hemolytic heparin. anemia, red cell aplasia) and white cell disorders (autoimmune neutropenia, platelet disorders, coagulopathy). Hemolytic anemia can be autoimmune or micro-angiopathic. Dermatological Dermatological paraneoplastic paraneoplastic syndromes syndromes include pruritic conditions; pigmentation conditions (Acanthosis nigricans, Vitiligo); erythematous conditions (necrolytic migratory erythema, exfoliative dermatitis- cutaneous); and bullous conditions (pemphigus, dermatitis herpetiformis). Other paraneoplastic Other paraneoplastic Treatment modalities for hypertrophic syndromes syndromes include osteroarthropathy include anti-tumor therapy, hypertrophic non-steroidal antiinflammatories, corticosteroids, osteroarthropathy. and radiation. AIDS-related AIDS-related malignancies The primary goal of treatment of Karposi's malignancies include Karposi's sarcoma, sarcoma is to prolong life. Localized treatments non-Hodgkin's lymphoma, include cryotherapy and laser, intra-lesional primary central nervous chemotherapy with vinblastine or interferon, and system (CNS) lymphoma, radiotherapy. Systemic treatment is required if Hodgkin's disease, cervical there is widespread cutaneous or visceral cancer, and anal cancer. involvement. Immunotherapy with interferon is effective. Treatment with vincristine and bleomycin is also used; doxorubicin may be added. Liposomal chemotherapeutics look promising. Treatments such as taxol, beta HCG, trans-retinoic acid, and anti-angiogenic agents such as thalidomide are being tested. For treatment of non-Hodgkin's lymphoma. systemic treatment with chemotherapy is usually used. Radiotherapy may be useful in localized disease. Standard treatment for advanced disease is combination chemotherapy, typically CHOP. Comcomitant intrathecal chemotherapy with mexotrexate and cytarabine is also used. More aggressive chemotherapy regimens may be useful. For primary CNS lymphoma, treatment involves whole-brain radiotherapy in combination with steroids and perhaps intrathecal chemotherapy. Hodgkin's disease is treated by standard chemotherapy is with ABVD (adriamycin, bleomycin, vinblastine, dacarbazine).

The formulations of the present invention comprise a therapeutically effective amount of the nitric oxide mimetic formulated together with one or more pharmaceutically acceptable carriers. As used herein, the term “pharmaceutically acceptable carrier” means a non-toxic, inert solid, semi-solid or liquid filler, diluent, encapsulating material or formulation auxiliary of any type. Some examples of materials which can serve as pharmaceutically acceptable carriers are sugars such as lactose, glucose and sucrose; starches such as corn starch and potato starch; cellulose and its derivatives such as sodium carboxymethyl cellulose, ethyl cellulose and cellulose acetate; powdered tragacanth; malt; gelatin; talc; excipients such as cocoa butter and suppository waxes; oils such as peanut oil, cottonseed oil; safflower oil; sesame oil; olive oil; corn oil and soybean oil; glycols; such a propylene glycol; esters such as ethyl oleate and ethyl laurate; agar; buffering agents such as magnesium hydroxide and aluminum hydroxide; alginic acid; pyrogen-free water; isotonic saline; Ringer's solution; ethyl alcohol, and phosphate buffer solutions, as well as other non-toxic compatible lubricants such as sodium lauryl sulfate and magnesium stearate. Coloring agents, releasing agents, coating agents, sweetening, flavoring and perfuming agents, preservatives and antioxidants can also be present in the formulation according to the judgment of the formulator. The formulations of this invention can be administered to humans and other animals orally, rectally, parenterally, intracisternally, intravaginally, intraperitoneally, topically (as by powders, ointments, or drops), supralingually (on the tongue) sublingually (under the tongue), bucally (held in the buccal pouch), or as an oral or nasal spray. The oral spray may be in the form of a powder or mist which is delivered to the deep lungs by oral inhalation.

In yet other embodiments, the invention provides topical sustained and prolonged release pharmaceutical compositions comprising one or more pharmacological compounds described supra, and a pharmaceutically acceptable carrier, to treat a malignant cell phenotype disorders. One example of a topical formulation includes 75% (w/w) white petrolatum USP, 4% (w/w) paraffin wax USP/NF, lanolin 14% (w/w), 2% sorbitan sesquioleate NF, 4% propylene glycol USP, and 1% compound of the present invention. Such compositions are useful in the treatment of cancer and in controlling and reducing pain associated therewith. Such compositions may comprise a unit dosage of one or more particular active agent(s) (e.g., a NO donor, calcium channel blocker, cholinergic modulator, α-adrenergic receptor antagonist, β-adrenergic receptor agonist, phosphodiesterase inhibitor; cAMP-dependent protein kinase activator, superoxide scavenger, potassium channel activator, SOC inhibitors, benzodiazepine, adrenergic nerve inhibitor, antidiarrheal agent, HMG-CoA reductase inhibitor, smooth muscle relaxant, adenosine receptor modulator, adenylyl cyclase activator, cAMP mimetic, endothelin receptor antagonist, bisphosphonate, cGMP-dependent protein kinase activator, and cGMP mimetic. Preferably, the compositions are administered in unit dosage form to a subject in need of such treatment. Topical sustained and prolonged release compositions are typically variants which include 1) an absorbent in a hydrophilic base; 2) an absorbent in a hydrophobic base; and 3) coated beads containing an absorbent matrix dispersed in a suitable vehicle. Also provided are methods of treating cancer comprising topically administering an effective amount of such compositions (e.g., in unit dosage form) to the appropriate area of the subject in need of such treatment.

Such hydrophilic compositions and preparations of the invention comprise a compound of the invention and a polymer, such as cellulose (methyl cellulose, ethyl cellulose, hydroxy propyl cellulose, etc.), higher molecular weight polyethylene glycol, methacrylic-acrylic acid emulsion, hydrogel, carbopol, ethyl vinyl acetate copolymer, or polyester, etc., to bind the compound of interest to the polymer. The compound-polymer matrix is then dispersed in a hydrophilic vehicle to form a semi-solid. After administration of such hydrophilic composition into the appropriate area, the water in the semi-solid preparation is adsorbed and the polymer matrix with the active ingredient (i.e., the pharmaceutical compound) remains as a coating in the area to which it has been applied. The pharmaceutical compound is then slowly released from this coating.

Hydrophobic compositions and preparations of the invention employ similar polymers as used in the hydrophilic preparations, but the polymer/compound matrix is dispersed into a vehicle, such a plastibase, in the hydrophobic compositions and preparations. Plastibase is a mineral oil base that only partially dissolves the pharmaceutical compound. The semi-solid composition forms a thin coating to which the composition has been applied such as, e.g., the vagina or urethral tract) and slowly releases the active compound. The prolonged action is controlled principally by the solubility of the active ingredient in the vehicle.

The present invention also provides coated beads which are produced by first absorbing a compound of the present invention, or a combination of compounds, on a cellulosic material blended with polyethylene glycol, filler, binder and other excipients. The resulting matrix is then extruded and spheronized (e.g., the process of making into spheres) to create small beads. The beads are then coated to an appropriate thickness with one or more of a suitable material, such as a methacrylic-acrylic polymer, polyurethane, ethyl vinyl acetate copolymer, polyester, silastic, etc. The coating on the beads acts as a rate controlling membrane that regulates the release of the compound from the core beads.

In other embodiments, the invention provides pharmaceutical compositions suitable for oral administration which are provided in unit dosage form comprising per unit dosage a NO donor, calcium channel blocker, cholinergic modulator, α-adrenergic receptor antagonist, β-adrenergic receptor agonist, phosphodiesterase inhibitor, cAMP-dependent protein kinase activator, superoxide scavenger, potassium channel activator, SOC inhibitors, benzodiazepine, adrenergic nerve inhibitor, antidiarrheal agent, HMG-CoA reductase inhibitor, smooth muscle relaxant, adenosine receptor modulator, adenylyl cyclase activator, cAMP mimetic, endothelin receptor antagonist, bisphosphonate, cGMP-dependent protein kinase activator, cGMP mimetic, and a pharmaceutically acceptable carrier. Such compositions are useful for treating cancer, including those disorders and conditions described above.

For delivery to the buccal membranes, typically an oral formulation, such as a lozenge, tablet, or capsule is used. Methods of manufacture of these formulations are known in the art, including but not limited to, the addition of a pharmacological agent to a pre-manufactured tablet; cold compression of an inert filler, a binder, and either a pharmacological compound or a substance containing the compound (as described in U.S. Pat. No. 4,806,356); and encapsulation. Another oral formulation is one that can be applied with an adhesive, such as the cellulose derivative, hydroxypropyl cellulose, to the oral mucosa, for example as described in U.S. Pat. No. 4,940,587. This buccal adhesive formulation, when applied to the buccal mucosa, allows for controlled release of the pharmacological agent into the mouth and through the buccal mucosa. The compounds of the present invention can be incorporated into these formulations as well.

For delivery to the nasal or bronchial membranes, typically an aerosol formulation is employed. The term “aerosol” includes any gas-borne suspended phase of the pharmacological agent that is capable of being inhaled into the bronchioles or nasal passages. Specifically, aerosol includes a gas-borne suspension of droplets of the compounds of the instant invention, as may be produced in a metered dose inhaler or nebulizer, or in a mist sprayer. Aerosol also includes a dry powder composition of a pharmacological compound of interest suspended in air or other carrier gas, which may be delivered by insufflation from an inhaler device, for example. For solutions used in making aerosols, the preferred range of concentration of the pharmacological agent is 0.1-100 mg/ml, more preferably 0.1-30 mg/ml, and most preferably, 1-10 mg/ml. Usually the solutions are buffered with a physiologically compatible buffer such as phosphate or bicarbonate. The usual pH range is 5 to 9, preferably 6.5 to 7.8, and more preferably 7.0 to 7.6. Typically, sodium chloride is added to adjust the osmolarity to the physiological range, preferably within 10% of isotonic. Formulation of such solutions for creating aerosol inhalants is discussed in Remington, Pharmaceutical Sciences, see also, Ganderton, et al., Drug Delivery to the Respiratory Tract, Ellis Horwood (1987); Gonda, Critical Reviews in Therapeutic Drug Carrier Systems, 6:273-313 (1990); and Raeburn, et al., J. Pharmacol. Toxicol. Methods, 27:143-159 (1992).

Liquid dosage forms for oral administration include pharmaceutically acceptable emulsions, microemulsions, solutions, suspensions, syrups and elixirs. In addition to the active compounds, the liquid dosage forms may contain inert diluents commonly used in the art such as, for example, water or other solvents, solubilizing agents and emulsifiers such as ethyl alcohol, isopropyl alcohol, ethyl carbonate, ethyl acetate, benzyl alcohol, benzyl benzoate, propylene glycol, 1,3-butylene glycol, dimethylformamide, oils (in particular, cottonseed, groundnut, corn, germ, olive, castor, and sesame oils), glycerol, tetrahydrofurfuryl alcohol, polyethylene glycols and fatty acid esters of sorbitan, and mixtures thereof. Besides inert diluents, the oral formulations can also include adjuvants such as wetting agents, emulsifying and suspending agents, sweetening, flavoring, and perfuming agents. Injectable preparations, for example, sterile injectable aqueous or oleaginous suspensions can be formulated according to the known art using suitable dispersing or wetting agents and suspending agents. The sterile injectable preparation can also be a sterile injectable solution, suspension or emulsion in a nontoxic parenterally acceptable diluent or solvent, for example, as a solution in 1,3-butanediol. Among the acceptable vehicles and solvents that can be employed are water, Ringer's solution, U.S.P. and isotonic sodium chloride solution. In addition, sterile, fixed oils are conventionally employed as a solvent or suspending medium. For this purpose, any bland fixed oil can be employed including synthetic mono- or diglycerides. In addition, fatty acids such as oleic acid are used in the preparation of injectables.

The injectable formulations can be sterilized, for example, by filtration through a bacterial-retaining filter, or by incorporating sterilizing agents in the form of sterile solid compositions which can be dissolved or dispersed in sterile water or other sterile injectable medium prior to use.

In cases where it is desirable to prolong the effect of the nitric oxide mimetic, the absorption of the nitric oxide mimetic from subcutaneous or intramuscular injection can be slowed. This can be accomplished by the use of a liquid suspension of crystalline or amorphous material with poor water solubility. The rate of absorption of the nitric oxide mimetic then depends upon its rate of dissolution which, in turn, may depend upon crystal size and crystalline form. Alternatively, delayed absorption of a parenterally administered formulation is accomplished by dissolving or suspending the nitric oxide mimetic in an oil vehicle. Injectable depot forms are made by forming microencapsule matrices of the drug in biodegradable polymers such as polylactide-polyglycolide. Depending upon the ratio of drug to polymer and the nature of the particular polymer employed, the rate of drug release can be controlled. Examples of other biodegradable polymers include poly(orthoesters) and poly(anhydrides). Depot injectable formulations can also be prepared by entrapping the nitric oxide mimetic in liposomes or microemulsions which are compatible with body tissues.

Formulations for rectal or vaginal administration are preferably suppositories, sponges or rings, which can be prepared by mixing the nitric oxide mimetics with suitable non-irritating excipients or carriers such as cocoa butter, polyethylene glycol or a suppository wax which are solid at ambient temperature but liquid at body temperature and therefore melt in the rectum or vaginal cavity thereby releasing the nitric oxide mimetic.

Solid dosage forms for oral administration include capsules, tablets, pills, powders, and granules. In such solid dosage forms, the nitric oxide mimetic is mixed with at least one inert, pharmaceutically acceptable excipient or carrier such as sodium citrate or dicalcium phosphate and/or: fillers or extenders such as starches, lactose, sucrose, glucose, mannitol, and silicic acid; binders such as carboxymethylcellulose, alginates, gelatin, polyvinylpyrrolidinone, sucrose, and acacia; humectants such as glycerol; disintegrating agents such as agar-agar, calcium carbonate, potato or tapioca starch, alginic acid, certain silicates, and sodium carbonate; solution retarding agents such as paraffin; absorption accelerators such as quaternary ammonium compounds; wetting agents such as cetyl alcohol and glycerol monostearate; absorbents such as kaolin and bentonite clay; and lubricants such as talc, calcium stearate, magnesium stearate, solid polyethylene glycols, sodium lauryl sulfate, and mixtures thereof. In the case of capsules, tablets and pills, the dosage form may also comprise buffering agents.

Solid compositions of a similar type can also be employed as fillers in soft and hard-filled gelatin capsules using such excipients as lactose or milk sugar as well as high molecular weight polyethylene glycols and the like. The solid dosage forms of tablets, capsules, pills, and granules can be prepared with coatings and shells such as enteric coatings and other coatings well known in the pharmaceutical formulating art. They may optionally contain opacifying agents and can also be of a composition that they release the nitric oxide mimetic only, or preferentially, in a certain part of the intestinal tract, optionally, in a delayed manner. Examples of embedding compositions which can be used include polymeric substances and waxes.

Powders and sprays can contain, in addition to the nitric oxide mimetic, excipients such as lactose, talc, silicic acid, aluminum hydroxide, calcium silicates and polyamide powder, or mixtures of these substances. Sprays can additionally contain customary propellants such as chlorofluorohydrocarbons or alternative non CFC propellants such as DIMEL, also referred to as 1,3,4-A.

Dosage forms for topical or transdermal administration of nitric oxide mimetics include ointments, pastes, creams, lotions, gels, powders, solutions, sprays, inhalants or patches. The nitric oxide mimetic is admixed under sterile conditions with a pharmaceutically acceptable carrier and any preservatives and/or buffers as may be required. Ophthalmic formulation, ear drops, eye ointments, powders and solutions are also contemplated as being within the scope of this invention. Transdermal patches have the added advantage of providing controlled delivery of the nitric oxide mimetic to the body. Such dosage forms can be made by dissolving or dispensing a nitric oxide mimetic in the proper medium. Absorption enhancers can also be used to increase the flux of the nitric oxide mimetic across the skin. The rate can be controlled by either providing a rate controlling membrane or by dispersing the nitric oxide mimetic in a polymer matrix or gel.

The ointments, pastes, creams and gels may contain, in addition to a nitric oxide mimetic, excipients such as animal and vegetable fats, oils, waxes, paraffins, starch, tragacanth, cellulose derivatives, polyethylene glycols, silicones, bentonites, silicic acid, talc and zinc oxide, or mixtures thereof.

A preferred mode of delivery is one which provides a reasonably steady-state delivery of the nitric oxide mimetic, so as to maintain steady-state plasma concentrations. Such delivery avoids any substantial initial spike in plasma concentration of the agent, as it would be desirable to avoid plasma concentrations that produce negative side effects. Transdermal patches and pulsed delivery systems are preferred modes of delivery.

For those formulations containing a nitric oxide mimetic which is commercially available, the low dose formulations for use in the method of the present invention are preferably formulated according to the same methods as the commercially available higher dose formulations, but with lower amounts sufficient to increase, restore or maintain nitric oxide mimetic activity to cells at a level which inhibits or prevents malignant cell phenotypes and/or enhances the efficacy of an antimalignant therapeutic modality. Methods of formulation are within the skill of pharmaceutical formulation chemists and are fully described in such works as Remington's Pharmaceutical Science, 18^(th) Edition, Alfonso R. Gennaro, Ed., Mack Publishing Co., Easton, Pa., USA, 1990.

The methods and formulations of the present invention are particularly useful in inhibiting metastases and development of resistance of tumor cells to antimalignant therapeutic modalities including, but not limited to chemotherapeutic agents, radiation therapy, immunotherapies, and thermal therapies. Examples of classes of chemotherapeutic agents useful in combination with low dose NO mimetics include, but are not limited to: anti-angiogenic agents including, but not limited to anti-VEGF agents, alkylating agents such as nitrogen mustards, alkyl sulfonates, nitrosoureas, ethylenimines, and triazenes; antimetabolites such as folate antagonists, purine analogues, and pyrimidine analogues; antibiotics such as anthracyclines, bleomycins, dauxorubicin, mitomycin, dactinomycin, and plicamycin; endothelin activating agents; enzymes such as L-asparaginase; farnesyl-protein transferase inhibitors; 5α reductase inhibitors; inhibitors of 17β-hydroxy steroid dehydrogenase type 3; hormonal agents such as glucocorticoids, estrogen or antiestrogens, androgens or antiandrogens, progestins, and luteinizing hormone-releasing hormone antagonist; octreotide acetate: microtubule-disruptor agents, such as ecteinascidins and analogs and derivatives thereof; microtubule-stabilizing agents such as taxanes, for example, TAXOL (paclitaxel), TAXOTERE (docetaxel) and thereof analogs, and epothilones or analogs thereof; vinca alkaloids; epipodophyllotoxins; topoisomerase inhibitors; prenyl-protein transferase inhibitors; and other agents such as hydroxyurea, procarbazine, mitotane, hexamethylmelamine, platinum coordination complexes such as cisplatin and carboplatin, biological response modifiers, growth factors, and immune modulators or monoclonal antibodies. Representative examples of chemotherapeutic agents in these classes useful in the present invention include but are not limited to, actinomycin D, aflacon, bleomycin sulfate, buserelin, busulfan, carmustin, chlorambucil, cladribin, cyclophosphamide, cytarabine, dacarbazine, daunorubicin, discodermolides, doxorubicin hydrochloride, estramustine, estramustine phosphate sodium, etoposide, etoposide phosphate, fludarabine, fluorouracil, flutamide, idarubicin, ifosfamide, interferon, interleukins, leuprolide, levamisole, lomustine, mechlorethamine hydrochloride, melphalan, mercaptopurine, methotrexate, mitomycin C, paclitaxel, pentastatin, pteridine, quinocarcins, rituximab, safracins, saframycins, semustine, streptozocin, tamoxifen, teniposide, thioguanine, thiotepa, topotecan, vinblastine, vincristine, vinorelbine tartrate, aldesleukin (Interleukin-2; proleukin), alemtuzumab (Campath; monocloncal antibody against 21-28 kDa cell surface glycoprotein CD52), altretamine (Hexylen; hexamethylmelamine; HMM), amifostine (Ethyol; WR2721), aminoglutethimide (Cytadren; Epithen), amsacrine (m-AMSA; AMSA; Amsidyl), anastrozole (Arimidex), arsenic trioxide (Trisenox), asparaginase (Elspar; L-Asparagionase), bacillus calmette-guerin (BCG; TheraCyst; TICE), bexarotene (Targretin), bicalutamide (Casodex), capacitabine (Xeloda), carmustine (BCNU; Bischloronitrosourea), daunorubicin liposome (DaunoXome), denileukin diftitox (Ontak; DAB₃₈₉IL-2), dexrazoxane (Zinecard; ICRF-187), docetaxel (Taxotere), doxorubicin (Adria' DOX; Rubex; Adriamycin; hydroxydaunorubicin), doxorubicin liposome (Doxil), epirubicin (Ellence; EPI;), erythropoietin (Procrit; Epogen; EPO), exemestane (Aromastin), filgrastim (Neupogen; G-CSF [granulocyte colony stimulating factor]), floxuridine (FUDR; 5-fluoro-2-deoxyuridine), 5-fluorouracil (5-FU; Efudex), gemcitabine (Gemzar), gemtuzumab ozogamicin (CMA-676; Mylotarg), goserelin (Zoladex), imatinib (STI570; gleevec; CGP₅₇₁₄₈B), interferon alpha (Intron A; Roferon), irinotecan (CPT-11; Camptosar), isotretinoin (Accutane; 13-cis-retinoic acid), letrozole (Femara), mechlorethamine (Mustargen), megestrol acetate (Megace), mesna (Mesnex; 2-mercaptoethanesulfonic acid), mitomycin-C (Mutamycin), mitoxantrone (Novantrone; DHAD; DHAQ), nilutamide (Nilandron), oxaliplatin (Eloxatin; DACH-platinum), pemetrexed (Alimta; LY231514), pentostatin (dCF; Nipent; 2′-deoxycoformycin), procarbine (Matulane; Natulanar; N-Methylhydrazine), raltitrexed (Tomudex; ZD1694), sargramostim (Leukine; GM-CSF[granulocyte monocyte colony stimulating factor]), streptozocin (Zanosar; Streptozotocin), UFT (Uracil; Tegafur), temozolomide (Temodar), thalidomide (Thalomid), toremifene (Fareston), trastuzumab (Herceptin, Anti-HER-2 antibocy; rhuMAbHER2), tretinoin (Vesanoid; all-trans retinoic acid), trimetrexate (TMTX; Neutrexin; TMQ), vinorelbine (Navelbine), and any analogs or derivatives thereof.

Animals suffering from cancer can be administered a low dose of a nitric oxide mimetic to inhibit the metastatic potential of the tumor cells as well as to enhance the efficacy of a co-administered antimalignant therapeutic modality targeted at killing the cancer cells. In this embodiment, the nitric oxide mimetic can be administered to animals in combination with other antimalignant therapeutic modalities, following, prior to or during surgical removal or a tumor, and/or following, during, or prior to radiation or thermal therapy. It is believed that this therapy will also enhance the efficacy of anti-VEGF agents targeted at inhibiting angiogenesis of vascular endothelial cells to tumors. In this embodiment, low dose nitric oxide mimetic therapy can be administered to an animal prior to, with, or following administration of an anti-VEGF agent such as anti-VEGF antibody. In this embodiment, it is preferred that the nitric oxide therapy be maintained at least throughout the known active period of the anti-VEGF agent. Low dose nitric oxide mimetic therapy can also be administered as prophylactic therapy to animals at high risk for developing cancer to prevent the development of cells with a malignant cell phenotype. In this embodiment, a low dose of the nitric oxide mimetic may be administered daily to the animal throughout its life. Accordingly, administration of long-term sustained release dosing formulations may be preferred in these animals. In addition, low dose nitric oxide therapy can be administered to animals suspected of, or known to be, exposed to a factor which lowers cellular nitric oxide mimetic activity so as to induce cells with a malignant cell phenotype. Administration of this low dose nitric oxide therapy is expected to inhibit development of a malignant cell phenotype in these animals. In this embodiment, it is preferred that the nitric oxide mimetic therapy be administered for at least as long as the animal is exposed to the factor. For example, both surgery and anesthesia are believed to be factors which lower cellular nitric oxide mimetic activity so as to induce a malignant cell phenotype. Accordingly, prior to or during a surgical procedure and/or administration of an anesthetic agent in an animal, the animal can also be administered a low dose of a nitric oxide mimetic to prevent and inhibit a malignant cell phenotype. In this embodiment, it is preferred that the nitric oxide mimetic be administered for at least the time in which the animal is undergoing the surgical procedure and/or is under the effects of anesthesia. Similarly, an animal subjected to physical trauma, especially a physical trauma associated with blood loss, a decrease in blood volume or hemorrhage can be administered a low dose of a nitric oxide mimetic to prevent and inhibit a malignant cell phenotype. It is believed that co-administration of a low dose of a nitric oxide mimetic can also be used to inhibit or prevent a malignant cell phenotype which may occur upon administration of pharmacological agents which alter the circulation, e.g. antihypertensives. In this embodiment, the nitric oxide mimetic is preferably administered on a daily basis with the other agents or in a long-term sustained release formulation which extends over the period in which the other agent is administered.

The following nonlimiting examples are provided to further illustrate the present invention.

EXAMPLES I. Example 1 Materials and Methods

A. Materials

Tissue culture medium (RPMI 1640) and fetal bovine serum (FBS) were purchased from Gibco BRL (Grand Island, N.Y.). Hypoxic conditions were generated using airtight chambers from BellCo Biotechnology (Vineland, N.J.). GTN was obtained as a solution (TRIDIL, 5 mg ml⁻¹ or 2.22 M) in ethanol, propylene glycol and water (1:1:1.33) from DuPont Pharmaceuticals (Scarborough, ON). Sodium nitroprusside (SNP) was purchased from Sigma Chemical Co. (St. Louis, Mo.). RNA extractions were conducted using a PURESCRIPT RNA isolation kit from Gentra Systems (Minneapolis, Minn.). For the Northern blot analyses, the nylon membranes used for the RNA transfers were purchased from Micron Separations, Inc. (Westboro, Mass.); the uPAR and PAI-1 cDNA probes were cloned in a Bluescript plasmid vector; the [³²P]-dCTP and the Reflection NEF film were purchased from Dupont/New England Nuclear (Mississauga, ON); and the oligolabelling kit was obtained from Pharmacia Biotech (Piscataway, N.J.). For the in vitro invasion assays, the serum-free EX-CELL 300 culture medium was purchased from JRH Biosciences (Lenexa, Kans.), the Costar TRANSWELL inserts (6.5 mm diameter polycarbonate, membrane, 8 μm pore) were purchased from Corning Costar (Cambridge, Mass.), and the reconstituted basement membrane (MATRIGEL) was bought from Collaborative Biomedical Products (Bedford, Mass.). The plasminogen activator inhibitor-1 (PAI-1) enzyme-linked immunosorbent assay (ELISA) kit was obtained from American Diagnostica (Greenwich, Conn.). For the Western blot analysis of uPAR, the resolved proteins were transferred to Immobilon-P membranes from Millipore (Bedford, Mass.), anti-uPAR antibody (monoclonal antibody [MoAb] 3937) was purchased from American Diagnostica (Greenwich, Conn.), the blotting grade affinity purified goat anti-mouse IgG (H+L) horseradish peroxidase conjugate was obtained from BIO-RAD (Hercules, Calif.), and the antigen was detected by enhanced chemiluminescence (ECL) using reagents from Amersham Canada (Mississauga ON). For the zymographic analyses, the gelatin was purchased from BDH (Toronto, ON), the casein was bought from Sigma Chemical Co. (St. Louis, Mo.) and the plasminogen was from American Diagnostica (Greenwich, Conn.).

B. Cells

The HTR-8/SVneo invasive trophoblast cell line and the MDA-MB-231 metastatic breast carcinoma cell line were used in these experiments. Both the HTR-8/SVneo and the MDA-MB-231 cells were cultured in RPMI-1640 medium supplemented with 5% FBS.

The HTR-8/SVneo cell line was obtained from explant cultures of human first trimester placenta and immortalized by transfection with a cDNA construct encoding the SVneo large T antigen. These cells have been previously characterized and have been maintained in culture for over 130 passages in RPMI 1640 medium supplemented with 5% FBS. They exhibit a high proliferation index and share various phenotypic similarities with the non-transfected parent HTR-8 cells such as in vitro invasive ability and lack of tumorigenicity in nude mice.

The MDA-MB-231 cell line was initially isolated in 1973 from the pleural effusion of a 51-year-old breast cancer patient (Callieau et al. J. Nat. Cancer Inst. 1974 53:661-674).

C. Hypoxic Cell Culture Conditions

Cells were placed in an airtight chamber and were flushed with a gas mixture containing 5% CO₂:95% N₂ until the oxygen concentration was 0%, as read by a Minioxl Oxygen Analyzer (Catalyst Research Corp., Owing Mills, Md.). The cells were then incubated at 37° C. Within the first 2 hours of incubation, the oxygen level in the chambers had equilibrated to approximately 1%, and remained at this level for the remainder of the incubation period.

Alternatively, cells were placed in a chamber in which atmospheric O₂ levels were maintained by a PRO-OX O₂ regulator (Biospherix, Redfield, N.Y.).

D. Treatment of Cells with Glyceryl Trinitrate (GTN) and Sodium Nitroprusside (SNP)

In these experiments, the cells were treated with varying concentrations of GTN and SNP. The stock solution of GTN was first diluted in phosphate-buffered saline (PBS) to a concentration of 10⁻⁴ M. Following filtration, the GTN solution was diluted in the culture medium to concentrations ranging from 10⁻⁴ M to 10⁻¹¹ M. The SNP (originally in crystal form) was dissolved in distilled water and diluted to a concentration of 10⁻⁵M. Following filtration, the SNP was diluted in the culture medium to concentrations ranging from 10⁻⁶ M, to 10⁻¹²M.

E. Northern Blot Analyses

Cells were cultured with varying concentrations of GTN and SNP under hypoxic (1% O₂) or control (20% O₂) conditions at 37° C. In another set of experiments MDA-MB-231 cells were incubated in the presence or absence of LMMA (0.5 mM) for 24 hours under various levels of oxygen (1%, 5% or 20% O₂) at 37° C. Following incubation, the total cellular RNA from the cells was isolated using the Gentra PURESCRIPT RNA Isolation Kit. The isolated RNA was subsequently separated by electrophoresis, and transferred to charged nylon membranes. The membranes were prehybridized at 42° C. for approximately 2 hours in a solution containing 50% formamide, 5×Denhardt's solution, 0.5% sodium dodecyl sulfate (SDS), 6×SSC (1×SSC=0.15 M NaCl, 15 mM sodium citrate, pH 7.0) and 100 μg/mL denatured salmon sperm DNA. They were then hybridized with a [³²P]-dCTP-labeled cDNA probe (uPAR or PAI-1) for approximately 24 hours at 42° C. in a solution composed of 6×SSC, 0.5% SDS, 100 μg/mL denatured salmon sperm DNA and 50% formamide, and containing a cDNA probe (uPAR or PAI-1) which was labeled with [³²P]-dCTP using a Pharmacia Oligolabelling kit. Following serial washes, the membrane was used to expose Dupont Reflection NEF film. After 1-4 days, the film was developed and analyzed. To correct for differences in the amount of RNA loaded in each sample, 28S rRNA was used.

F. Western Blot Analysis of uPAR Protein Levels

To examine the level of uPAR protein, the cells were first cultured with 20% O₂ or 1% O₂ in the presence of varying concentrations of SNP or GTN. Following incubations, the cells were lysed using a buffer containing 40 mM HEPES pH 7.2, 100 mM NaCl, 20% glycerol, 0.1 mM EDTA pH 8.0, 0.2% Triton X-100, 1 mM DTT, and 2 mM PMSF. The lysates were then subjected to homogenization, DNA shearing (10 times with a 25⅝-gauge needle), boiling (5 minutes) and centrifugation (15 minutes, 14000 g). The supernatant was collected and stored at −80° C. until use. The samples were subjected to SDS-polyacrylamide gel electrophoresis (PAGE) and the resolved proteins were transferred to an Immobilon-P membrane using a wet transfer apparatus (Bio-Rad Laboratories, Mississauga, ON). The membranes were blocked overnight at 4° C. in a solution containing 1% PBS, and 0.01% Tween20 (PBS-T) as well as 5% casein. The blots were subsequently incubated for 1.5 hours with the monoclonal anti-uPAR antibody [MoAb 3937], followed by six 5 minute washes with PBS-T. The membranes were then incubated with a horseradish peroxidase labeled goat anti-mouse IgG secondary antibody for 1.5 hours. Following six additional 5 minute washes with PBS-T, the antigen was detected by enhanced chemiluminescence and the blots were exposed onto Dupont Reflection NEF film.

G. Measurement of Metalloproteinase and Plasminogen Activator Activity by Zymography

To measure the levels of metalloproteinase and plasminogen activator activity, the cells were incubated under hypoxic or control conditions in the presence of varying concentrations of SNP or GTN. The cells were cultured using a serum-free medium (EX-CELL 300). Following incubation, the medium was extracted and centrifuged at 5,000 RPM for 5 minutes. The supernatant was subsequently collected and stored at −80° C. until further use. SDS-polyacrylamide gels were prepared in accordance with well-known procedures. For the analysis of metalloproteinase secretion, the gel contained 0.1% w/v gelatin, and for the analysis of plasminogen activator secretion, the gel was supplemented with 0.1% w/v casein as well as plasminogen (50 μg/mL). The serum-free conditioned medium was then combined with a nonreducing sample loading buffer (0.5 M Tris, 10% SDS, 1% Bromophenol Blue in 2 mL glycerol) in a ratio of 4:1 and was not boiled. Following electrophoresis, the gels underwent two 15 minute washes with 2.5% Triton X-100. This step removed the SDS. After the washes with H₂O, the gels were incubated overnight at 37° C. in a solution containing Tris-HCl (pH 7.0) and CaCl₂ (5 mM). The gels were stained with 0.4% Coomassie Brilliant Blue R-250 in 40% methanol/10% glacial acetic acid/50% distilled water for approximately 1 hour, and then destained for about 2 hours in 30% methanol/10% glacial acetic acid/60% distilled water. Molecular weight standards showed as dark bands against the lighter blue background and colorless zones appeared where lysis occurred. In the gelatin-containing gels, these areas corresponded to metalloproteinase (gelatinase) activity and in the casein gels, these bands corresponded to plasminogen activator activity. The gels were preserved using a preserving solution (10% glacial acetic acid/10% glycerol/80% distilled water) for 1 hour and were dried on cellophane for 1 hour at 60° C.

H. In Vitro Invasion Assays

Matrigel invasion chambers (modified Boyden chambers) were used to assess the invasive ability of the cells under hypoxic and standard conditions in the presence or absence of various concentrations of GTN or SNP. The chambers consist of cell culture inserts, 6.5 mm in diameter and with a 8 μm pore size membrane. Each membrane was coated with 100 μL of a 1 mg/mL solution of Matrigel diluted in cold serum-free culture medium (EX-CELL 300), and allowed to dry in a laminar flow cabinet for approximately 12 hours. The Matrigel was then rehydrated by incubating it with 100 μL of serum-free medium for approximately 1 hour. After rehydration, cell suspensions containing 5.0×10⁴ or 1.0×10⁵ cells in 100 μL of medium, containing both serum and the nitric oxide treatments, were added to each well. Culture medium containing serum and the respective nitric oxide treatment were then added to each insert. The cells were incubated for 24 hours under either hypoxic (1% O₂) or control (20% O₂) conditions. Following incubation, the non-invading cells were removed from the upper surface of the membrane by wiping with a cotton swab. The cells on the lower surface of the membrane were fixed for 10 minutes with Carnoy's fixative (25% acetic acid, 75% methanol), and then stained for approximately 3 hours with a 1% toluidine blue, 1% sodium borate solution. Following a rinse in phosphate-buffered saline (PBS), the membrane was removed from the insert housing with a small scalpel blade, mounted onto a microscope slide and coverslipped. Invading cells were then viewed under the microscope at 40× magnification and counted. The invasion index for each treatment was calculated by dividing the number of invading cells by the number of cells which invaded under standard conditions. This value was then multiplied by 100 to obtain a percentage. The standard was given a value of 100% and the treatment values were converted to a percentage of the standard. The results were tested for statistical significance using either the Tukey test for pair-wise multiple comparison procedures or the Student-Newman-Keuls method for pair-wise multiple comparison procedures. See FIG. 1.

I. In Vivo Metastasis Model

C57BL6 mice were injected i.v. (tail vein) with a bolus of 5×10⁴-10⁵ Bl6F10 metastatic melanoma cells. Immediately after the tail vein injection, mice were randomly divided into groups of 15 and mice in each group were placed in plexiglass chambers (approximately 3 L) which were continuously flushed with gas mixtures of 20% O₂:balance N₂ and 10% O₂:balance N₂, respectively. Gas flows were adjusted to a level which did not allow CO₂ build-up within the chambers. After a 24 hour exposure to an atmosphere of either 20% O₂ or 10% O₂, mice were removed from the chambers and placed in regular cages kept at room air. Thirteen days later, mice were sacrificed by cervical dislocation, and lungs were removed and fixed in Bouin's fixative (Sigma). Metastatic nodules (many of which appeared black due to the presence of melanin) on the surface of the lungs were counted visually under a dissecting microscope. Data were expressed as the number of lung nodules per 10⁴ cells injected and were analyzed using statistical tests for non-parametric values.

In a second set of experiments, the same protocol was followed except that the Bl6F10 mouse melanoma cells were incubated for 12 hours in 1% or 20% oxygen in the presence or absence of 2×10⁻¹¹ M GTN. Cells were then removed from plates with trypsin and 5×10⁴ cells were injected i.v. (tail vein) into C57BL6 female mice. See FIG. 2. Some of the cells treated in vitro were plated onto tissue culture dishes to determine colony-forming ability using the protocol described below in the Section I.J.

J. Colony Formation Assay for Doxorubicin Resistance

The resistance of MDA-MB-231 breast cancer cells to doxorubicin was determined following culture in 20% or 1% oxygen by counting the number of colonies formed. MDA-MB-231 cells were incubated in 1% O₂ or 20% O₂ for 24 hours. Following incubation, the cells were exposed to diluent (control), 25 μM doxorubicin, 25 μM doxorubicin plus 10⁻⁶ M GTN or 25 μM doxorubicin plus 10¹⁰ M GTN for 1 hour. The cells were washed and then plated onto 35 mm plates at different dilutions. The cells were incubated for an additional 1-2 weeks in order to allow cell colonies to grow. At the end of the incubation period, the cells were fixed with Carnoy's fixative, stained with Crystal violet, rinsed and allowed to air dry. Colonies were counted visually. The surviving cells under each condition was determined by counting the number of colonies and was expressed as a fraction of the number of colonies that survived without doxorubicin exposure.

II. Example 2 The Activation of sGC and PKG is Linked to the Regulation of Invasive and Metastatic Phenotypes

A. Materials

Glyceryl Trinitrate (GTN) at a concentration of 2.22 M (Sabex, Boucherville, QC) and Diethylenetriamine/nitric oxide adduct (DETA-NONOate) (SIGMA Chemical Co., St. Louis, Mo.) were used as NO-mimetics. Desferoxamine mesylate (DFO) (SIGMA Chemical Co., St. Louis, Mo.) was used as an iron chelator. 1H-[1,2,4]Oxadiazolo-[4,3-a]Quinoxalin-1-One (ODQ) (SIGMA Chemical Co., St. Louis, Mo.), was used to selectively inhibit soluble guanylyl cyclase. Various concentrations 8-bromoguanosine 3′:5′-cyclic monophosphate (8-Br-cGMP) (SIGMA Chemical Co., St. Louis, Mo.) were used to activate cGMP-dependent protein kinase (PKG), and KT5823 (Calbiochem, La Jolla, Calif.) was used to selectively inhibit PKG.

B. Cells

The HTR-8/SVneo line was established from explant cultures of human first trimester placenta and was immortalized by transfection with the large T antigen of simian virus 40. These cells exhibit similar in vitro invasive abilities to their parent HTR-8 cells, and are not tumourigenic in nude mice. They have been maintained in culture for over 130 passages, and require at least 5% serum in order to sustain growth in vitro (see, Graham, Hawley, et al. 1993 ID: 1080).

The MDA-MB-231 is a metastatic breast cancer cell line that was initially isolated in 1973 from a 51-year-old patient {Cailleau, Young, et al. 1974 ID: 982}.

A metastatic murine melanoma (B16 F10) (a kind gift of Dr. Ann Chambers, London Regional Cancer Centre, London, ON) was utilized in the experimental metastasis experiments.

All of the cell cultures were maintained in monolayer culture in RPMI 1640 medium (Gibco BRL, Grand Island, N.Y.) supplemented with 5% fetal bovine serum (FBS; Gibco BRL) in a standard Sanyo CO₂ incubator (5% CO, in air, 37° C.; Esbe Scientific, Markham, ON).

C. Culture Conditions

In order to establish hypoxic culture conditions, cells were placed in airtight chambers (BellCo Biotechnology, Vineland, N.J.) which were flushed with a gas mixture of 5% CO₂/95% N₂ until the desired oxygen concentration was reached. Oxygen levels were maintained through the use of a Pro-Ox Model 110 oxygen regulator (Reming Biospherix, Redfield, N.Y.).

D. Northern Blot Analysis

Following incubation, the total cellular RNA was isolated using a GENTRA PURESCRIPT® RNA Isolation Kit (Gentra Systems, Minneapolis, Minn.). The isolated RNA was subsequently separated by electrophoresis, transferred to a charged nylon membrane (Micron Separations Inc., Westboro, Mass.) and fixed with ultraviolet radiation using a UV Crosslinker (NAME). The membranes were prehybridized at 68° C. for approximately 1 hour in a prewarmed ultrasensitive hybridization buffer, ULTRAhyb™ (Ambion, Austin, Tex.). They were then hybridized overnight at 68° C. with a DIG-labeled uPAR probe. In order to generate the probe, a uPAR cDNA cloned in a Bluescript plasmid vector was linearized. The linear cDNA subsequently underwent in vitro transcription with a DIG-labelled RNA labeling mix and T3 RNA polymerase (Roche Molecular Biochemicals, Indianapolis, Ind.). Following hybridization, the membranes were washed twice in 2×SSC, 0.1% SDS (5 minutes at 68° C.) and then twice in 0.1×SSC, 0.1% SDS (15 minutes at 68° C.). Bands were detected using a DIG luminescent detection kit (Roche Molecular Biochemicals, Indianapolis, Ind.) and the membrane was exposed to Dupont Reflection NEF film (Dupont/New England Nuclear, Mississauga, ON).

E. Western Blot Analysis

Following incubation, the cells were lysed using a buffer containing 40 mM HEPES pH 7.2, 100 mM NaCl, 20% glycerol, 0.1 mM EDTA pH 8.0, 0.2% Triton X-100, 1 mM dithiothreitol (DTT), and 2 mM phenylmethyl sulfonyl fluoride (PMSF). The lysates were then subjected to homogenization, DNA shearing (10 times with a 25⅝-gauge needle), boiling (5 minutes) and centrifugation (15 minutes at 14,000×g). The supernatant was collected and stored at −80° C. until use. The samples were subjected to SDS-polyacrylamide gel electrophoresis (PAGE) and the resolved proteins were transferred to an Immobilon-P membrane (Millipore Corp., Bedford, Mass.) using a wet transfer apparatus (BioRad Laboratories, Mississauga, ON). The membranes were blocked overnight at 4° C. in a solution containing 1% PBS, and 0.01% Tween 20 (PBS-T) as well as 5% dry milk powder. The blots were subsequently incubated for 1.5 hours with the monoclonal anti-uPAR (MoAb 3937; American Diagnostica Inc., Greenwich, Conn.), or a polyclonal soluble guanylate cyclase (sGC) antiserum (Cayman Chemical, Ann Arbor, Mich.) followed by six 5-minute washes with PBS-T. Subsequently, the uPAR membranes were incubated for 1 hour with a horseradish peroxidase labelled goat anti-mouse IgG secondary antibody (Bio-Rad, Hercules, Calif.) and the sGC membranes were incubated for 1 hour with a goat anti-rabbit IgG horseradish peroxidase conjugate (VECTOR Laboratories Inc., Burlingame, Calif.). Following six additional 5-minute washes with PBS-T, the antigen was detected by enhanced chemiluminescence (Amersham Canada Inc., Mississauga, ON) and the blots were exposed onto Dupont Reflection NEF film.

F. In Vitro Invasion Assays

Matrigel invasion assays were used to assess the effect of 8-Br-cGMP on the ability of cells to penetrate through an extracellular matrix. The chambers consisted of 6.5-mm inserts with 8-μm pore membranes (Corning Costar Corp., Cambridge, Mass.). Each membrane was coated with 100 μL of a 2.6 mg/mL solution of Matrigel (Collaborative Biochemical Products, Bedford, Mass.) diluted in cold serum-free medium (EX-CELL 300; JRH Biosciences, Lenexa, Kans.), and allowed to dry in a laminar flow cabinet for approximately 12 hours. The Matrigel was then rehydrated with 100 μL of serum-free medium for approximately 1 hour. After rehydration, cell suspensions containing 5.0×10⁴ cells in 100 μL of RPMI, as well as serum (5% FBS) and 8-Br-cGMP, were added to each well. The cells were incubated for 24 hours in either 1% or 20% oxygen. Following incubation, the non-invading cells were removed from the upper surface of the membrane by wiping with cotton tipped swabs. The cells on the lower surface of the membrane were fixed for 2 minutes with ice-cold methanol, and stained overnight with a 1% toluidine blue, 1% sodium borate solution. Following a rinse in phosphate-buffered saline (PBS), the membrane was removed from the insert with a small scalpel blade, mounted on a microscope slide and cover-slipped. Invading cells were then viewed under the microscope at 40× magnification and counted. The invasion index for each treatment was calculated by dividing the number of invading cells by the number of cells that invaded under standard (20% oxygen) conditions. Invasion indices were expressed as percentages of control (20% oxygen) values. The results were tested for statistical significance using analysis of variance followed by either the Tukey or the Student-Newman-Keels tests for pair wise multiple comparisons.

G. In Vivo Metastasis Experiment

A murine metastasis model was used to assess the effect of 8-Br-cGMP on the metastatic potential of Bl6-F10 melanoma cells. The cells were incubated for 12 hrs in 1% or 20% oxygen and in the presence or absence of 8-Br-cGMP (1 μM). Following harvesting from culture plates, 5×10⁴ cells were injected intravenously (tail vein injections) into 5-7 week old C57Bl/6 female mice. Cells were also plated in tissue culture plates to determine the effect of culture conditions on in vitro colony forming ability. Fourteen days after intravenous inoculation, mice were sacrificed and their lungs were removed and fixed in Bouin's fixative. Both melanotic and amelanotic metastatic colonies were counted under a dissecting microscope. Data were expressed as the number of lung nodules per 5×10⁴ viable cells injected (as determined by in vitro colony-forming ability) and were analyzed using statistical tests for non-parametric values.

H. Measurement of Guanylate Cyclase Levels and Activity

The effects of hypoxia and NO-mimetic treatment on sGC levels were determined using Western Blot analysis. To determine sGC activity, cGMP levels were measured. Briefly, cells were extracted over ice in 1 mL of 6% trichloroacetic acid (BDH Laboratory Supplies, Poole, England). The homogenate was then centrifuged at 13,000 g for 10 min. The supernatant fraction was removed and extracted five times with 2 mL of water-saturated diethyl ether (BDH). The cGMP contained in this fraction was subsequently acetylated and quantitated using an enzyme-linked immuno-sorbent assay (ELISA) kit (STI—Signal Transduction Products, San Clemente, Calif.).

Results

I. The Role of Soluble Guanylate Cyclase in the NO Mimetic Prevention of Hypoxia Induced uPAR Upregulation

To determine whether a heme protein, such as sGC played a role in the ability of NO mimetics to inhibit the hypoxic upregulation of uPAR, the iron chelator Desferroxamine (DFO) (100 μM) was used. It was found that the upregulation of uPAR that occurred in response to heme disruption with DFO could not be inhibited by GTN (10⁻¹⁰ M, 10⁻⁶ M). These results suggest that the NO-mimetic effect is mediated via a heme moiety.

Western blot analysis was used to determine the effects of various oxygen concentrations as well as NOS blockade on sGC protein levels. It was found that the total sGC levels remained unchanged, regardless of the treatment employed. Conversely, using an ELISA for cGMP it was found that sGC activity is decreased after only 2 hours of hypoxia (0.5% O₂). Further, this reduction was significantly prevented by the addition of GTN (10⁻¹⁰ M, 10⁻⁶ M).

The selective sGC inhibitor ODQ (0.5 μM) was used to determine the role of sGC in the NO mimetic prevention of uPAR upregulation. It was found that the ability of GTN (10⁻⁶ M) to abrogate the hypoxic induction of uPAR was substantially prevented by ODQ at both the protein and mRNA levels.

J. The Role of PKG in the NO Mimetic Prevention of Hypoxia Induced uPAR Upregulation

To determine the role of PKG in the in the oxygen mediated control of uPAR, the PKG activator 8-Br-cGMP (10⁻³-10⁻⁷ M) was added to cells cultured in 20 and 0.5% O₂ or in the presence of DFO (100 μM). In accordance to previous studies, uPAR expression was markedly increased under hypoxic conditions and in the presence of DFO at both the protein and mRNA levels. Interestingly, this induction was significantly abrogated by the addition of 8-Br-cGMP. To assure that the 8-Br-cGMP was activating PKG, a PKG inhibitor (KT5823, 10 μM) was added to the medium. It was found that KT5823 could induce the expression of uPAR, even in the presence of oxygen and that it significantly blunted the effects of 8-Br-cGMP.

K. The Effects of 8-Br-cGMP on Hypoxia-Induced Invasion and Metastasis

As a functional correlate of uPAR expression, an in vitro invasion assay was conducted. It was found that 8-Br-cGMP could significantly inhibit hypoxia-associated invasion.

To extend these findings, an in vivo metastasis assay was conducted. In accordance to previous studies, culture of the Bl6 F10 cells in hypoxic conditions (1% O₂) resulted in a marked increase in metastatic lung nodules. This induction was completely abrogated by the addition of 8-Br-cGMP (1 μM). Using a colony formation assay it was found that the 8-Br-cGMP treatment did not affect the viability of the cells.

L. The Effects of No Mimetics on the Hypoxic Upregulation of In Vitro Invasion and Expression of uPAR

To determine the effect of NO mimetics on hypoxia during in vitro invasiveness, an in vitro invasion assay was conducted. While hypoxia increased the in vitro invasiveness of MDA-MB-231 breast carcinoma cells by more than 5-fold (FIG. 5), it was found that low concentrations of two different NO-mimetic drugs, glyceryl trinitrate (GTN; 1 pM and 0.1 μM; P<0.002 and P<0.001 respectively; one-way ANOVA followed by Fisher's test) and sodium nitroprusside (SNP; 10 pM; P<0.001), administered at the beginning of the 24-hour invasion assay.

MDA-MB-231 cells were cultured in 0.5% oxygen for 24 hours to determine the effect on uPAR protein levels. It was found that exposure to 0.5% oxygen resulted in up to 3.5-fold increases (P<0.0001) in uPAR protein levels (FIGS. 6A and 9B) and up to 5-fold increases (P<0.0002) in uPAR mRNA levels (FIGS. 6C, 8A, and 9A). Administration of single doses of GTN (1 pM, 1 nM, and 0.1 μM) to cells incubated for 24 hours in 0.5% oxygen was sufficient to prevent the upregulation of uPAR protein expression (FIG. 6A; P<0.004, <0.005 and <0.001 for each concentration of GTN, respectively). Similarly, the hypoxia-mediated increase in uPAR mRNA levels was also inhibited when a low concentration of GTN (a pM) was used (FIG. 6C; P<0.001).

M. The Effects of NO Synthase Inhibition on uPAR Protein and mRNA Levels

To assess whether endogenous NO inhibits uPAR expression, NO synthesis in MDA-MB-231 cells was blocked by incubation with the NOS inhibitor N-monomethyl-L-arginine (L-NMMA, 0.5 mM). In a manner characteristic of cells exposed to hypoxia, a 24-h incubation with a single dose of L-NMMA resulted in an overall 50% increase in the levels of uPAR protein (FIG. 6B; P<0.004) and a 2.8-fold increase in uPAR mRNA levels in MDA-MB-231 cells even when cultured in 20% O₂ (FIG. 6D; P<0.04). In contrast, compared with uPAR expression in cells incubated in 20% O₂ alone, no significant increase in uPAR protein (P=0.89) or transcript (P=0.35) levels was observed in cells incubated with a combination of L-NMMA (0.5 mM) and GTN (0.1 nM) in 20% O₂ (FIGS. 6B and 6D).

N. The Effects of Hypoxia on sGC Signaling

To determine the effect of hypoxia on cGMP levels, MDA-MB-231 breast carcinoma cells were incubated in 0.5% O₂ for 6 hours in the presence of IBMX (500 μM). The results from an ELISA for cGMP revealed that, compared with cells incubated in 20% O₂, the MDA-MB-231 cells incubated in 0.5% O₂ exhibited a 50% reduction in accumulated cGMP levels (P<0.002; FIG. 7A). This effect of hypoxia on cGMP levels was prevented by co-incubation with the NO mimetic GTN (1 μM).

Western Blot analysis was conducted to determine the effects of hypoxia on sGC protein levels. Soluble GC is a heterodimeric protein consisting of an α1 and a β1 subunit. Culture in hypoxia for 24 hours resulted in a 44% decrease in the levels of the β1 subunit (P<0.0001). In contrast, culture in hypoxia resulted in a 2.3-fold increase (P<0.02) in the levels of the a1 subunit (FIG. 7B). Although the ratio of the α1 and the β1 subunits was altered during hypoxia, the total amount of sGC was not significantly changed.

O. The Role of sGC in the NO-Mediated Inhibition of uPAR Expression

To determine the effect of sGC blocker on the levels of uPAR mRNA, MDA-MB-231 cells were incubated for 24 hours with the selective sGC blocker (ODQ, 0.5 μM). Compared with incubation of cells under control conditions (20% 0, alone), the treatment described above resulted in a 2.7-fold increase (p<0.05) in the levels of uPAR mRNA (FIG. 8A). While the presence of GTN (1 μM) prevented the hypoxic upregulation of uPAR mRNA expression, GTN was unable to block the effect of hypoxia when ODQ was also present in the medium (FIG. 8A).

Soluble GC is a heme-containing enzyme that requires ferrous iron for its biosynthesis and activity. Therefore, to further assess the participation of this enzyme in the regulation of uPAR expression by the NO signaling pathway, MDA-MB-231 cells were cultured in the presence of DFO, which resulted in a 4-fold increase (P<0.007) in the levels of uPAR mRNA (FIG. 8C). In contrast to hypoxia, the effect of DFO on uPAR mRNA expression was not prevented by 1 μM of GTN.

Furthermore, the upregulation of uPAR mRNA and protein expression by hypoxia was significantly reduced (P<0.0001) in a dose-dependent manner (up to 100%) by the presence of 8-Br-cGMP (0.1 μM-10 μM; 24 hours), a non-hydrolysable analogue of cGMP (FIGS. 9A and 9B). Interestingly, the presence of 8-Br-cGMP (1 mM) also resulted in the complete inhibition (P<0.01) of the DFO-induced upregulation of uPAR mRNA expression (FIG. 9C). These results indicate that a major component of the hypoxia- and DFO-mediated stimulation of uPAR expression is the inhibition of sGC.

P. Role of PKG in the NO Mediated Inhibition of uPAR Expression

To further elucidate the role of NO signaling in the regulation of uPAR expression, MDA-MB-231 cells were incubated for 6 hours with the PKG inhibitor KT5823 (10 μM). Northern and Western blot analyses revealed that selective inhibition of PKG, even in 20% O₂, resulted in a 1.8-fold (P<0.05) increase in uPAR protein and mRNA expression (FIGS. 10A and 10B). These results demonstrate that PKG activation by cGMP is necessary for the inhibition of uPAR expression by NO.

Q. Effect of 8-Br-cGMP on Hypoxia-Induced Invasion

To determine the effect of 8-Br-cGMP on hypoxia-induced invasion, an in vitro invasion assay was conducted. Results from the in vitro invasion assay using matrigel as a substrate for invasion revealed that, compared to the invasiveness of cells incubated in 20% O₂, hypoxia stimulated the invasiveness of MDA-MB-213 cells by 3.9 fold (P<0.0001; FIG. 11). This effect of hypoxia on invasiveness was completely inhibited by the presence of various concentrations of 9-Br-cGMP (0.1 μM-1 mM; FIG. 11).

III. Example 3 The Role of Nitric Oxide in Hypoxia-Induced Chemoresistance in Prostate Cancer Cells

Low tumor oxygenation (hypoxia) correlates with increased metastasis and resistance to radiotherapy and chemotherapy. Hypoxia has been shown to be associated with human prostate cancer, and prostate cancers are often highly resistant to chemotherapy. To test whether hypoxia is a major contributor to reduced chemosensitivity in prostate cancer cells and that hypoxia-induced chemoresistance in prostate cancer cells can be inhibited by low concentrations of nitric oxide (NO) mimetic agents, human PC-3 and mouse TRAMP-C2 prostatic adenocarcinoma cells were incubated in 20% O₂ or 0.5% O₂ for 12 hours in the presence or absence of glyceryl trinitrate (GTN, 0.1 nM). This was followed by a one-hour incubation with doxorubicin and survival was assessed by colony formation assays. Western blot analysis was used to measure NO synthase (NOS) protein levels in cells cultured in 20% and 0.5% O₂. Pre-incubation of the two cell lines under hypoxia resulted in increased survival (up to 8-fold for the PC-3 cells and up to 12-fold for the TRAMP-C2 cells; P<0.0001) following exposure to doxorubicin. Co-incubation of the PC-3 and TRAMP-C2 cells with 1 nM of GTN resulted in complete inhibition of the hypoxia-induced resistance to doxorubicin (P<0.0001). Both cell lines expressed all three NOS isoforms (NOS I, NOS II and NOS III), but only the expression of NOS III was significantly increased (P<0.05) in PC-3 cells incubated in 0.5% versus 20% O₂. These findings indicate that NO plays an important role in the regulation of chemosensitivity in prostate cancer cells. Furthermore, the results indicate that administration of GTN provides a means of chemosensitizing prostatic carcinomas (FIGS. 12 and 13).

IV. Example 4 Multicellular Resistance to Doxorubicin is Attenuated by Nitric Oxide Mimetics

Previous studies revealed that hypoxia-induced drug resistance in tumor cells cultured in monolayer results from impaired nitric oxide (NO) production. It is also well established that, compared with culture in monolayer, tumor cells cultured as multicellular aggregates (spheroids) exhibit significantly higher levels of resistance to chemotherapeutic agents. The present study demonstrated that chemoresistance associated with spheroid culture is due to decreased NO signalling. Using human MDA-MB-231 breast carcinoma cells in clonogenic assays, survival was determined following doxorubicin exposure and NO mimetic administration to both monolayer and spheroid cultures. Compared with incubation in 20% O₂, monolayer cells incubated in 1% O₂ exhibited a three-fold increase in resistance to doxorubicin. Administration of glyceryl trinitrate (GTN), at 1 μM, resulted in a 50% attenuation of resistance. Incubation with 200 μM doxorubicin resulted in a 90% decrease in survival of tumor cells cultured as spheroids. Diethylenetriamine/nitric oxide adduct (DETA) at 0.1 mM and 2 μM, and GTN at 0.1 nM and 1 μM, did not affect the survival of control (doxorubicin-untreated) cells. However, these NO mimetics effectively attenuated the resistance to 200 μM doxorubicin associated with 3D culture by 90% and 30% respectively. These results demonstrate that treatment with NO mimetics can be used as a novel approach to increase the chemosensitivity of solid tumors (FIGS. 14 and 15).

V. Example 5 The Role of Camp Signaling in the Regulation of Breast Carcinoma Invasiveness

This example demonstrates that the hypoxia-induced increases in uPAR expression and invasion are mediated via a reduction in cGMP-dependent signaling. The cGMP and cAMP systems are intimately connected and cGMP levels have been shown to modulate cAMP levels. Given the importance of cGMP signaling in the regulation of invasiveness and its ability to modulate cAMP signaling, this study demonstrates the role of cAMP and its effector, cAMP-dependent protein kinase (PKA), in the regulation of carcinoma cell invasiveness.

Human breast carcinoma (MDA-MB-231) cells were cultured for 24 hours in 20% or 0.5% O₂ in the presence or absence of the adenylyl cyclase activator forskolin (10 μM) and/or the PKA inhibitor H-89 (1 μM). Northern and Western blot analyses showed that forskolin inhibited uPAR mRNA and protein expression at both 20% and 0.5% This effect of forskolin on uPAR expression was prevented by H-89, demonstrating that the effects of forskolin are mediated by the cAMP-dependent activation of PKA. Inhibition of PKA with H-89 also resulted in an up-regulation of uPAR expression that was independent of oxygenation. Using an in vitro invasion assay through reconstituted extracellular matrix (Matrigel®), forskolin inhibited cellular invasion at both 20% and 0.5% O₂. Inhibition of PKA activity with H-89 prevented this effect of forskolin and independently enhanced invasiveness. These findings demonstrate that cAMP-dependent signaling plays an important role in the regulation of carcinoma cell invasiveness, independently of oxygenation status. Furthermore, the cAMP pathway provides a novel pharmacological target for the inhibition of tumor cell invasion and metastasis.

VI. Example 6 Low Dose Nitroglycerin Treatment Decreases PSA Velocity

Methods: Patients with a previous history of prostatectomy that have experienced biochemical failure as per the ASTRO criteria (three successive rises in PSA), PSA<10 (units), stable with sub-clinical disease were included in the study after signing an informed consent. All patients were placed on treatment with continuous low dose transdermal nitroglycerin (˜0.03 mg/hr, 24 hours a day). Subjects returned to the study centre for monthly PSA measurements. Subjects were withdrawn from the study if there was evidence of disease progression or other intervening medical events.

Results: In general patients having 5 or more months of therapy have decreased mean PSA velocity from 14%/month to 5.4%/month, 4 of 9 subjects have completed 6 months of therapy. 1 subject (with negative margins) has experienced a decrease in PSA, the remaining 3 subjects (with positive margins) have experienced a decrease in PSA velocity, 3 subjects were withdrawn due to: initiation of cardiac medication, renal failure and MRI positive for spinal canal metastasis identified just after enrollment. No patients experienced drug related adverse events.

Conclusions: The current ongoing pilot open-label study indicates that the use of low dose nitric oxide donor treatment is safe and well tolerated in subjects that have experienced biochemical failure after radial prostatectomy. A benign treatment that provides a decrease in PSA velocity during the early phase of biochemical failure can provide a valuable adjunctive clinical tool in the management of prostate cancer. Based on the current data, the concept of low dose nitric oxide treatment of rising PSA associated with biochemical failure should be assessed in a randomized, placebo controlled clinical study.

VII. Example 7 Preventing the Progression of Cervical Intralesional Neoplasia (CIN) to Cervical Cancer

Cervical cancer is most common in developing countries. The cervix is the lower third of the uterus. Cancer of the cervix may originate on the vaginal surface or in the canal. Each year, an estimated 500,000 new cases are diagnosed worldwide with some 250,000 of those women destined to die of their disease. Ample evidence exists to show that both incidence and mortality can be reduced by the use of cervical screening program (Cain J M, et al, Science, 288:1753-1754, 2000). Currently, human papillomavirus (HPV), especially HPVs 16 & 18, has been implicated as the major causal agent in this disease. Symptoms of cervical cancer include vaginal bleeding, post-coital spotting, vaginal discharge, and in advanced cases, pelvic or low back pain with sciatic nerve toot type of pain radiating down to the lower back of the lower extremities.

Women typically receive annual gynecological examination that includes PAP smears which analyses the cytological abnormalities of the cervical epithelial cells. In 1988, a National Institute of Health consensus panel was formed and had a uniformed terminology for reporting cervical cytology. Low grade squamous intraepithelial lesions (LSIL) encompassing HPV changes are considered Grade I CIN. High-grade lesions encompassing Grade II & III CIN present high risk to progress cervical cancer. If the PAP smear results are positive, the next step could be colposcopy and directed biopsy. In patients with gross evidence of tumour, diagnosis is usually confirmed by a directed cervical punch biopsy (Benedet J L et al, International Journal of Gynecology & Obstetrics, 70 (2000), 209-262).

Women diagnosed with CIN of various Grades can be treated with low-dose nitrolycerin, either topically, vaginally, or parenterally, alone or in combination with the standard therapies as recommended by the FIGO Committee on Gynecologic Oncology. Regressing on the Grades of CIN will considered as treatment success. Furthermore, if patients had a Grade II or III CIN, and fail to progress to a confirmed diagnosis of cervical cancer with nitrolycerin treatment, one can conclude that the nitroglycerin treatment has successfully prevent the progression to malignant phenotype. Patients that are in the high risk group, e.g. multiple partners with high existence or potential for HPV infection can stay on the low-dose nitroglycerin treatment to prevent recurrence.

VIII. Example 8 Prolong the Effective Treatment Period and Enhance the Overall Effectiveness of Treating Hormone Refractory/Insensitive Breast Cancer Using Fourth-Line Treatment Option by Oral PDE V Inhibitor

Breast cancer is the most common cancer and the second leading cancer death in women. In the United States, there are approximately 100,000 women alive with metastatic breast cancer. Once metastases have developed, breast cancer is rarely, if ever, a “curable” condition. When managing metastatic disease, the treatment objectives are to optimize treatment response, improve survival, and balance these goals with maintaining highest possible quality of life. Some treatments are palliative in nature. With the exception of Herceptin (specific for the HER2 oncoprotein), cytotoxic chemotherapeutic agents remains the standard for advanced hormone insensitive breast cancer.

Advanced breast cancer patients where cancer had progressed on anthracycline, taxane and capecitabine treatment can be considered for the following treatment in order to improve the therapeutic index (relief of cancer symptoms vs. the likelihood of treatment-related toxicities) and overall quality of life. While being treated with one of the fourth-line treatments (e.g., Doxil, navelbine, gemcitabine), the breast cancer patients could also take oral PDE V inhibitor, Viagra 25 mg once daily or other longer lasting PDE V inhibitor such as vanadafil. Overall increase in survival rate and or survival time of these women in comparison with the historical database of a given fourth-line treatment will be considered a treatment success of the PDEV inhibitor, Viagra. Enhancing the quality of life, reduction of pain and discomfort during the survival period is also considered as support of Viagra effectiveness in treating breast cancer patients using fourth-line treatment approach. Viagra could also be used with glucocorticoids such as prednisone to provide additional palliative relief of cancer symptoms.

IX. Example 9 Preventing the Progression of Prostate Cancer

Prostate cancer is an important public health concern, representing the most common visceral cancer and the second leading cause of cancer deaths of North American males. In 1999, the American Cancer Society estimated that approximately 179,300 new cases of prostate cancer will be diagnosed in the United States and about 37,000 men could die of the disease (Landis et al. CA Cancer J Clin 1999 49:8-31). Despite this enormous prevalence, optimal management of both localized and metastatic disease remains elusive. Although screening efforts attempt to detect cancer at early stages, it has been estimated that 25% of men diagnosed with prostate cancer will eventually succumb to metastatic disease (Landis et al. CA Cancer J Clin 1999 49:8-31).

Radical prostatectomy is considered a gold therapy treatment of localized prostate cancer and removal of all prostatic tissue should result in undetectable serum PSA within a month if all disease has been eradicated (Landis et al. CA Cancer J Clin 1999 49:8-31); therefore, longitudinal measurement of PSA is currently the most sensitive method for detecting cancer persistence, relapse and progression following radical prostatectomy (Landis et al. CA Cancer J Clin 1999 49:8-31). Except for a few anecdotal reports of prostate cancer relapse in the absence of a PSA rise, clinical evidence of local or distant cancer failure is preceded by months to years with biochemical evidence (that is, a detectable PSA; Landis et al. CA Cancer J Clin 1999 49:8-31). The ten-year actuarial incidence of biochemical failure after radical prostatectomy for clinically localized prostate cancer ranges anywhere from 27% to 57% (Zeitman et al. Urology 1994 43:828-833). A ten-year clinical local recurrence rate of 8%, clinical distant recurrence rate of 9% and any evidence of failure (biochemical or clinical) of 32% have been reported. The median time to PSA evidence of treatment failure ranges from 19 to 24 months and the median interval from biochemical recurrence to clinical evidence of disease is an additional 19 months (range: 7 to 71 months).

Men diagnosed with prostate cancer can be treated with a low-dose NO mimetic such as nitroglycerin or isosorbide dinitrate, preferably orally, sublingually, topically, or parenterally, alone or in combination with the standard therapies (e.g., anti-androgen therapy, radical prostatectomy). Exemplary low-dose NO mimetic therapies are set forth herein in Table 1. Regression or stabilization of serial PSA values is considered a treatment success. Furthermore, if subjects have prostate cancer and fail to progress to a later stage of prostate cancer with low-dose NO mimetic such as nitroglycerin or isosorbide dinitrate treatment, one can conclude that the NO mimetic treatment has successfully prevented the progression of prostate cancer. Subjects in the high-risk group, e.g., with short PSA doubling times or family history can stay on a low-dose NO mimetic (e.g., nitroglycerin or isosorbide dinitrate) treatment indefinitely to prevent development, progression or recurrence of the disease.

X. Example 10 Preventing the Progression of Breast Cancer

There is evidence that the local tumor microenvironment plays an important role in determining the behavior of the tumor cells. Hypoxia (pO2 values of less than 10 mmHg) within the solid tumor mass is an independent marker of a poor clinical outcome for patients with a variety of cancers, and in particular breast cancer. The risk of mortality is significantly increased if a primary tumor undergoes metastasis to a distant site within the body.

Females diagnosed with breast cancer can be treated with a low-dose NO mimetic such as nitroglycerin or isosorbide dinitrate, preferably orally, sublingually, topically, or parenterally, alone or in combination with the standard chemotherapies (e.g. taxol). Exemplary low-dose NO mimetic therapies are set forth herein in Table 1. Regression or stabilization of a primary tumor is considered a treatment success. Subjects in the high-risk group (e.g. family history) can stay on a low-dose NO mimetic (e.g. nitroglycerin or isosorbide dinitrate) treatment indefinitely to prevent development, progression or recurrence of the disease.

XI. Example 11 Effect of GTN Therapy On PSA Levels

PSA levels, a biochemical marker of prostate cancer recurrence, were determined following GTN administration in patients with prostate cancer wherein the prostate is still intact.

In this prostate cancer patient, he received radiation therapy in 1991 as the treatment choice. Subsequently, he was place on anti-androgen therapy as the next line of treatment. One year later, there was an increase of serum PSA level as an indicator of cancer relapse. As shown in FIG. 16, the rate of increase in circulating PSA levels decreased in this patient following commencement of two separate episodes of administration of GTN at 0.03 mg/hour, 24 hours a day, for approximately one month each. In both periods, a reduction of PSA velocity was observed with GTN treatment. Following the commencement of a third episode of administration of GTN at 0.03 mg/hour, 24 hours a day, for approximately one month, a decrease in PSA levels was again observed. This result suggest that NO mimetics such as GTN could improve the effectiveness of anti-androgen therapy treatment alone in 1) time to biochemical failure indicated by continuous increase in PSA velocity and 2) in prolonging the time to full relapse of prostate cancer in men.

Further, as shown in FIG. 17, chronic administration of GTN, transdermally, at a concentration of 0.03 mg/hour dramatically improved the efficacy, as determined by circulating PSA levels, of radiation therapy. Two months after chronic GTN therapy was begun, this patient was administered radiation therapy. As shown in FIG. 17, this combination therapy accelerated the rate of PSA decrease to within three months. The expected average for a similar decrease in PSA levels following radiation therapy alone is twelve months. This result support the use of NO mimetics in enhancing the effectiveness of radiation therapy in treating prostate cancer patients by 1) decrease the serum marker of prostate cancer, i.e. PSA level, 2) potential lead to remission of prostate cancer and 3) maintaining prostate cancer at dormant stage indefinitely.

XII. Example 12

Prostate cancer is now the most commonly diagnosed cancer and the second most common cause of cancer death in men. Prostate cancer is mostly adenocarcinoma that arise from high-grade prostate intraepithelial neoplasia (PIN) which is present in 4-16.5% of needle biopsies and is strongly predictive of co-existing carcinoma, thus warranting a repeat biopsy. Early prostate cancer patients can be effectively treated with available androgen suppression therapy.

The treatment of hormone refractory advanced prostate cancer remains a clinical challenge. In hormone-refractory/insensitive prostate cancer (HRPC) patients who failed one non-estramustine, taxane-containing regimen and entering an estramustine treatment regimen (e.g. 14 mg/kg/day PO in 3-4 individual doses) will be provided with topical nitroglycerin ointment. The nitroglycerin ointment will be applied 4-5 times daily to provide sustained plasma level of nitric oxide. While under the nitroglycerin and estramustine treatment, the PSA levels will be measured monthly. The effect of nitroglycerin treatment will be measured against historical database of estramustine users. A statistic of ≧40% patients with ≧50% decrease in PSA levels or velocity will be considered a nitroglycerin treatment success. The overall increase in the expected median survival time of 5 months of estramustine mono-therapy, the reduction of pain score and the use of pain medication, or improvement in patients' ability to maintain cognitive function and to copy with the advanced disease will also considered as clinically meaningful to add nitroglycerin treatment to the standard of care of these patients.

Example 13 Preventing the Recurrence of Malignant Breast Cancer Following Lumpectomy Procedure

Patients with localized early stage non-metastatic breast cancer may elected to undergo a lumpectomy procedure to remove the malignant tissue. Prior to the surgery, patients may start with first line anti-malignant therapy to reduce the tumor volume. To improve the effectiveness of this treatment, patients could start taking nitric oxide mimetics such as Viagra (25 mg or 50 mg) daily continuously during the first line therapy, right after the surgery and chronically post-surgical procedure to prevent relapse of the breast cancer or other form of cancer. Prolong remission period against the history database and/or better quality of life will be considered a treatment success.

It is understood that the examples and embodiments described herein are for illustrative purposes only and that various modifications or changes in light thereof will be suggested to persons skilled in the art and are to be included within the spirit and purview of this application and scope of the appended claims. All publications, patents, and patent applications cited herein are hereby incorporated by reference in their entirety for all purposes. 

1. A method for controlling, treating and/or decreasing progression of cancer, malignancies, and/or tumor angiogenesis in a human subject, the method comprising: administering a low dose of a nitric oxide mimetic to the human subject, to control, treat, and/or decrease progression of cancer, malignancies, and/or tumor angiogenesis; wherein the nitric oxide mimetic is an organic nitrate; wherein the low dose is 3 to 10,000 fold lower than a dose of nitric oxide mimetic that produces vasodilation in the human subject; wherein the low dose of nitric oxide mimetic does not induce substantial tolerance in the human subject; and wherein the low dose is sustained for the duration of controlling, treating and/or decreasing progression of cancer, malignancies, and/or tumor angiogenesis in the human subject.
 2. The method of claim 1, wherein the nitric oxide mimetic is administered at a level which delays and/or reduces development of tolerance to the nitric oxide mimetic and/or unwanted side effects.
 3. The method of claim 1, wherein the nitric oxide mimetic is administered alone.
 4. The method of claim 1, wherein the nitric oxide mimetic: (1) inhibits the metastatic potential of a tumor or malignant cell phenotype by decreasing the invasiveness, progression, growth, and/or metastases of cells exhibiting a malignant phenotype; inhibiting the survival and/or growth of cells exhibiting a malignant phenotype; decreasing the progression and/or metastases of cells exhibiting a malignant phenotype; increasing the regression of cells exhibiting a malignant phenotype; and/or facilitating the killing of cells exhibiting a malignant phenotype; (2) maintains a malignant tumor in a dormant or quiescent state at its primary and/or secondary site; (3) enhances the efficacy of, and/or decreases the resistance to an antimalignant therapeutic modality; or (4) inhibits or decreases progression of tumor angiogenesis in a subject at high risk of developing cancer and/or exposed to factors known to decrease nitric oxide activity in the human subject, optionally wherein the factors include decreased arginine levels, exposure to nitric oxide synthase antagonists, exposure to nitric oxide scavengers, changes in nitric oxide synthase expression, change in cofactors, glucose deprivation, surgical procedures, administration of anaesthetic agents, administration of pharmacologic agents which alter circulation, traumatic injuries, physical trauma, blood loss, decreased blood volume, or hemorrhage, or combinations thereof.
 5. The method of claim 1, wherein the cells exhibiting the malignancies are selected from malignant cells, invasive cells, cells and tissue(s) that facilitate the malignant process, and combinations thereof; optionally wherein the malignant cell phenotype is controlled or treated, or its progression is decreased by improving response to an antimalignant therapeutic modality.
 6. The method of claim 1, wherein cancer is diagnosed or monitored by measuring a tumor selective marker present in the human subject.
 7. The method of claim 6, wherein the nitric oxide mimetic decreases or decelerates increases of the level of the tumor marker.
 8. The method of claim 1, wherein the cancer comprises gastric cancer, gastrointestinal cancer, testicular cancer, prostate cancer, prostatic adenocarcinoma, breast cancer, metastatic melanoma, colorectal cancer, or lung cancer, or combinations thereof; optionally wherein the cancer or other malignancies, and/or tumor angiogenesis in the human subject comprises benign prostatic hyperplasia or molar pregnancy.
 9. The method of claim 4, wherein the antimalignant therapeutic modality includes radiation therapy, thermal therapy, immunotherapy, or chemotherapy, or combinations thereof, optionally wherein the antimalignant therapeutic modality comprises radiation therapy and the nitric oxide mimetic is administered during the radiation therapy.
 10. The method of claim 9, wherein the chemotherapy comprises administration of a chemotherapeutic agent that is an anti-angiogenic agent, an antimetabolite, an antibiotic, an endothelin activating agent, an enzyme inhibitor, a hormonal agent, ocreotide acetate, a microtubule-disruptor agent, a microtubule-stabilizing agent, a vinca alkaloid, a epipodophyllotoxin, a topoisomerase inhibitor; a prenyl-protein transferase inhibitor, hydroxyurea, procarbazine, mitotane, hexamethylmelamine, a platinum coordination complex, a biological response modifier, a growth factor, an immune modulator, or a monoclonal antibody, or a combination thereof.
 11. The method of claim 1, wherein the nitric oxide mimetic is a known vasodilatory compound and the mimetic is administered at a dose of at least 3 to 10,000-fold lower than the dose of nitric oxide mimetic known to produce vasodilation in the human subject.
 12. The method of claim 2, wherein the unwanted side effects are selected from vasodilation, headache, flushing, syncope, dizziness, and hypotension.
 13. The method of claim 1, wherein the nitric oxide mimetic is administered in combination with an antimalignant therapeutic agent.
 14. The method of claim 1, wherein the dose of nitric oxide mimetic is 100 to 10,000-fold lower than a dose of nitric oxide mimetic that produces vasodilation in the human subject.
 15. The method of claim 1, wherein the nitric oxide mimetic is a known vasodilatory compound and is administered at a dose 100 to 10,000-fold lower than the dose known to produce vasodilation in the human subject.
 16. The method of claim 6, wherein the tumor selective marker is prostate specific antigen (PSA).
 17. The method of claim 1, wherein the cancer is prostate cancer.
 18. The method of claim 1, wherein the nitric oxide mimetic is nitroglycerin (GTN).
 19. The method of claim 1, wherein the nitric oxide mimetic is isosorbide 5-mononitrate (ISMN).
 20. The method of claim 1, wherein the nitric oxide mimetic is isosorbide dinitrate (ISDN).
 21. The method of claim 1, wherein the nitric oxide mimetic is pentaerythritol tetranitrate (PETN).
 22. The method of claim 1, wherein the nitric oxide mimetic is erythrityl tetranitrate (ETN).
 23. The method of claim 1, wherein the cancer is lung cancer.
 24. The method of claim 1, wherein the cancer is colorectal cancer. 